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The nurse prioritizes which nursing diagnosis for the client admitted with Guillain-Barré syndrome?

a. Ineffective Breathing Pattern related to skeletal muscle weakness b. Risk for Injury, Impaired Skin Integrity related to immobility
c. Self-care Deficit related to skeletal muscle weakness
d. Anxiety related to powerlessness

1 Answer

5 votes

Final answer:

The highest priority nursing diagnosis for a patient with Guillain-Barré syndrome is Ineffective Breathing Pattern due to the potential for respiratory failure from muscle weakness.

Step-by-step explanation:

The nurse prioritizes the nursing diagnosis of Ineffective Breathing Pattern related to skeletal muscle weakness for a client admitted with Guillain-Barré syndrome. Guillain-Barré syndrome is a demyelinating disease of the peripheral nervous system characterized by weakened muscles which may lead to respiratory failure, a potentially life-threatening condition. Close monitoring of respiratory status and support is vital due to the risk of rapidly progressing muscle weakness impacting the diaphragm and intercostal muscles.

While Risk for Injury, Impaired Skin Integrity related to immobility, Self-care Deficit related to skeletal muscle weakness, and Anxiety related to powerlessness are important diagnoses that the nurse may consider, the immediate life-sustaining need to ensure an effective breathing pattern is the highest priority.

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User Zztop
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