Which of the following nursing diagnoses would be MOST appropriate for a client with Guillain-Barré syndrome?
a. Ineffective breathing pattern related to loss of respiratory muscle function
b. Risk for injury related to inability to perceive danger in the environment, confusion, impaired judgment, and weakness
c. Pain related to pressure on the brain
d. Altered thought processes related to neuron degeneration and sleep deprivation
A
The motor weakness in Guillain-Barré syndrome usually begins distally, in the legs and progressing up the body. The major concern in these clients is when the weakness reaches the diaphragm and affects their breathing. Initially the focus will be on safety measures due to the weakness in the lower extremities.
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