The nurse is assessing a client who recently had an upper respiratory infection and now presents to the emergency department with lower extremity numbness and difficulty swallowing. Based on these findings, this client is at greatest risk for which pathophysiological condition?

Guillain-Barre syndrome.

Mycoplasma pneumonia.

Cytomegalovirus.

Epstein-Bar virus.

Answer and Explanation

The Correct Answer is A

A. Guillain-Barre syndrome is a condition that can occur after an upper respiratory infection and is characterized by progressive weakness, numbness, and sometimes difficulty swallowing, which align with the client's symptoms.

B. Mycoplasma pneumonia primarily affects the respiratory system and does not typically cause lower extremity numbness and difficulty swallowing.

C. Cytomegalovirus can cause a range of symptoms but is not specifically associated with lower extremity numbness and difficulty swallowing.

D. Epstein-Barr virus is linked to infectious mononucleosis and does not typically cause lower extremity numbness and difficulty swallowing.

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Correct Answer is D

Explanation

A. While impaired comfort is a concern, the priority is to address potential neurovascular compromise.

B. Impaired skin integrity is a concern but not the most immediate issue given the symptoms described.

C. Risk for infection is important but secondary to the acute concern of neurovascular function.

D. Risk for peripheral neurovascular dysfunction is the highest priority as it indicates potential compartment syndrome or other serious complications requiring urgent intervention.

A. Replace fluids IV based on intake and output. B. Turn every 2 hours around the clock from side-to-side. C. Record the amount of daily wound drainage. D. Assess skin condition and turgor for breakdown.

Correct Answer is A

Explanation

A. Fluid replacement is crucial to prevent dehydration and maintain electrolyte balance, which is vital in clients with severe ulcerative colitis and after surgery.

B. Turning the client is important to prevent pressure ulcers but is not as immediately critical as fluid balance.

C. Recording wound drainage is necessary but secondary to ensuring the client’s fluid and electrolyte status.

D. Assessing skin condition is important but fluid balance takes priority in this scenario.

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The nurse is assessing a client who recently had an upper respiratory infection and now presents to the emergency department with lower extremity numbness and difficulty swallowing. Based on these findings, this client is at greatest risk for which pathophysiological condition?

Nursing Test Bank

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Explanation

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