# Situation: A 38-year-old man is admitted to the neurology ward with Guillain-Barré syndrome (GBS). Leg weakness began 4 days ago and is spreading upward. He had diarrhea 2 weeks before. He weighs 70 kg and has no other illness. On day 5, during a 3-hour break between intravenous immunoglobulin (IVIG) infusions, his blood pressure ranges from 86/50 to 176/98 mmHg and his heart rate from 48 to 124/min. He has no pain and no fever, his abdomen is soft, and a bladder scan shows 90 mL. Which is the MOST likely cause?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630430  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 38-year-old man is admitted to the neurology ward with Guillain-Barré syndrome (GBS). Leg weakness began 4 days ago and is spreading upward. He had diarrhea 2 weeks before. He weighs 70 kg and has no other illness.

On day 5, during a 3-hour break between intravenous immunoglobulin (IVIG) infusions, his blood pressure ranges from 86/50 to 176/98 mmHg and his heart rate from 48 to 124/min. He has no pain and no fever, his abdomen is soft, and a bladder scan shows 90 mL. Which is the MOST likely cause?

## 보기

1. Dehydration from poor oral intake since admission
2. An infusion reaction to the immunoglobulin
3. Autonomic instability from the disease itself **✔ 정답**
4. Anxiety about the slow pace of his recovery

**정답: 3**

## 해설

Autonomic dysfunction is common in Guillain-Barré syndrome and causes wide swings in blood pressure and heart rate and dysrhythmias, so continuous cardiac monitoring is needed. The swings occurred while no immunoglobulin was running, and pain, fever, and bladder distension have been checked. Dehydration and anxiety raise the heart rate but do not explain severe hypertension alternating with bradycardia.

## 심화 해설

Recognizing dysautonomia
On day 5 the client's blood pressure swings between 86/50 and 176/98 mmHg and his heart rate between 48 and 124/min within a few hours. Wide, alternating swings in both directions are the signature of autonomic dysfunction (dysautonomia), which is common in Guillain-Barré syndrome. GBS can damage autonomic as well as motor fibers, producing labile blood pressure, alternating tachycardia and bradycardia, and dysrhythmias. Because these changes can be life-threatening, clients with GBS are placed on continuous cardiac monitoring.

How the stem rules out other causes
The question carefully removes the usual triggers of sympathetic surges. The swings occurred during a 3-hour break when no immunoglobulin was running. He has no pain and no fever, his abdomen is soft, and the bladder scan shows only 90 mL, so urinary retention and bowel distension, which can provoke autonomic surges, are absent. With those causes excluded, the most likely explanation is the disease itself.

Why the distractors do not fit
Each distractor explains only one direction of change.

| Option | Expected pattern | Why it fails here |
| --- | --- | --- |
| Dehydration | Low blood pressure with a fast pulse | Does not cause severe hypertension or bradycardia |
| Infusion reaction to IVIG | Fever, headache, chills, or anaphylaxis during infusion | No infusion was running and there is no fever |
| Autonomic instability | Alternating high and low blood pressure and heart rate | Matches the findings |
| Anxiety | High blood pressure and fast pulse | Does not cause hypotension with bradycardia |

Watch out! Do not choose dehydration just because the blood pressure dropped to 86/50. A single cause that explains all of the findings, including hypertension alternating with bradycardia, is the better answer.

Nursing response
The nurse keeps the client on continuous cardiac monitoring, measures blood pressure frequently, and reports extremes rather than treating every swing aggressively, because short-acting agents are preferred when treatment is needed. Positional changes are made slowly, and triggers such as a full bladder, constipation, or suctioning are minimized. Key point! In GBS, labile blood pressure and heart rate without another cause point to autonomic involvement, which calls for continuous cardiac monitoring.

## 임상 시나리오

Autonomic Instability in GBSLabile blood pressure and heart rate
Day 5: blood pressure 86/50 to 176/98 mmHg and heart rate 48 to 124/min, with no pain, fever, distension, or urinary retention, and no infusion running.

GBS can affect autonomic fibers, causing swings in both directions and dysrhythmias. Dehydration, infusion reactions, and anxiety each explain only one direction of change.

The nurse maintains continuous cardiac monitoring, changes position slowly, avoids triggers such as a full bladder, and reports extremes to the physician.

CautionAutonomic dysfunction can cause sudden bradycardia or dysrhythmia; never stop cardiac monitoring because the client looks well.

## 핵심 개념

- **Dysautonomia** — Dysfunction of the autonomic nervous system that causes unstable blood pressure, heart rate, sweating, and bowel or bladder control.
- **Intravenous immunoglobulin** — Pooled antibodies from donors given by infusion to modulate the immune attack in Guillain-Barré syndrome.
- **Bladder scan** — A portable ultrasound measurement of urine volume in the bladder, used to detect retention.
- **Continuous cardiac monitoring** — Ongoing ECG display of heart rate and rhythm to detect dysrhythmias as they occur.

## 같은 주제 문제

- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630316)
- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630317)
- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630318)
- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630319)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630320)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630321)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630322)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630323)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._