What is the priority nursing intervention for the child with ascending paralysis as a result of Guillain-Barré syndrome (GBS)?
a. Immunosuppressive medications
b. Respiratory assessment
c. Passive range-of-motion exercises
d. Anticoagulant therapy
B
Feedback
A Children with rapidly progressing paralysis are treated with intravenous
immunoglobulins for several days. Administering this infusion is not the nursing
priority.
B Airway is always the number one priority. Special attention to respiratory status
is needed because most deaths from GBS are attributed to respiratory failure.
Respiratory support is necessary if the respiratory system becomes compromised
and muscles weaken and become flaccid.
C The child with GBS is at risk for complications of immobility. Performing
passive range-of-motion exercises is an appropriate nursing intervention, but not
the priority intervention.
D Anticoagulant therapy may be initiated because the risk of pulmonary embolus as
a result of deep vein thrombosis is always a threat. This is not the priority
nursing intervention.
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