The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication?

A. Hyperglycemia:
Although hyperglycemia can occur as a result of stress or corticosteroid use during the treatment of GBS (such as in the case of plasma exchange or IV immunoglobulin (IVIG) therapy), it is not the primary complication associated with GBS. While hyperglycemia requires monitoring and management, respiratory failure is a more immediate and critical concern.

B. Urinary retention:
Urinary retention can occur in some clients with neurologic disorders like GBS, but it is not as life-threatening as respiratory failure. The autonomic nervous system, which controls bladder function, may be affected, but urinary retention is usually manageable with intermittent catheterization or other interventions. It does not carry the same immediate risks to life or organ function as respiratory failure.

C. Respiratory failure:
In Guillain-Barré syndrome (GBS), the immune system attacks the peripheral nervous system, which can lead to progressive muscle weakness and paralysis. The most significant and potentially life-threatening complication of GBS is respiratory failure. This occurs because the paralysis can affect the muscles involved in breathing, including the diaphragm and intercostal muscles, leading to impaired ventilation. As the weakness progresses, the client may become unable to maintain effective breathing, requiring mechanical ventilation. Monitoring for signs of respiratory distress (e.g., increasing work of breathing, tachypnea, decreased breath sounds, or a drop in oxygen saturation) is critical in GBS, especially during the acute phase of the disease.

D. Hypertension:
Hypertension may be seen in some cases of GBS, particularly during the early stages of the disease, due to the autonomic dysfunction that can result from nerve involvement. However, hypotension (low blood pressure) is more commonly associated with the autonomic dysfunction in GBS rather than hypertension. Regardless, respiratory failure remains the most urgent complication to monitor for in clients with GBS.

A. pH 7.36, PaO2 98 mmHg, PaCO2 27 mmHg, HCO3 16 mEq/L, O2 sat 99%: This set of ABG results is consistent with fully compensated metabolic acidosis. pH 7.36: This is within the normal range (7.35-7.45), indicating that compensation has occurred, as the pH has returned to normal levels. PaCO2 27 mmHg: The PaCO2 is low, suggesting that the respiratory system has compensated for the metabolic acidosis by increasing ventilation to excrete CO2, thus reducing the acid load. HCO3 16 mEq/L: The bicarbonate level is low, which is consistent with metabolic acidosis as the primary disturbance. The PaO2 and O2 saturation are normal, indicating adequate oxygenation. Since the pH is within the normal range and the PaCO2 and HCO3 levels reflect the compensatory changes needed to correct the metabolic acidosis, this is a case of fully compensated metabolic acidosis.

B. pH 7.47, PaO2 91 mmHg, PaCO2 52 mmHg, HCO3 30 mEq/L, O2 sat 96%:

This result indicates alkalosis rather than acidosis. The pH is alkalotic (7.47), and PaCO2 is elevated (52 mmHg), which suggests respiratory acidosis as the primary disturbance. The HCO3 is also high (30 mEq/L), which is consistent with metabolic compensation for respiratory acidosis, not for metabolic acidosis. Therefore, this is not consistent with fully compensated metabolic acidosis.

C. pH 7.45, PaO2 86 mmHg, PaCO2 56 mmHg, HCO3 28 mEq/L, O2 sat 94%:

The pH is normal, but PaCO2 is elevated (56 mmHg), indicating respiratory acidosis rather than metabolic acidosis. The HCO3 is also elevated (28 mEq/L), which is consistent with compensation for respiratory acidosis, not metabolic acidosis. This result suggests respiratory acidosis with compensated metabolic alkalosis rather than metabolic acidosis.

D. pH 7.32, PaO2 88 mmHg, PaCO2 54 mmHg, HCO3 29 mEq/L, O2 sat 94%:

The pH of 7.32 indicates acidosis, but it is not within the normal range, so this is not fully compensated. The PaCO2 is elevated (54 mmHg), indicating respiratory acidosis, and the HCO3 is elevated (29 mEq/L), showing metabolic compensation. However, since the pH has not yet returned to normal (it remains acidotic), this is an example of partially compensated respiratory acidosis, not fully compensated metabolic acidosis.

respiratory acidosis, not fully compensated metabolic acidosis.