Difficulty: Medium
Average Score: 65%
Full-length
Passage / Scenario
The nurse is caring for a 43-year-old client.Nurses' Notes Vital Signs
Emergency Department
0800: A 43-year-old client comes to the emergency department due to lower back pain and bilateral leg weakness. The client reports that the weakness began 3 days ago in the feet and has gradually worsened. The client sought treatment today after becoming "so weak that I fell while walking" and noticing new hand weakness and difficulty swallowing. Back pain radiates down both legs and is rated as 5 on a scale of 0-10. The client recently recovered from an illness with flu-like symptoms. The client reports a history of hypertension and takes no medications. Assessment of the lower extremities reveals muscle strength of 2/5 and decreased sensation to pinprick. Achilles tendon and patellar reflexes are decreased
Select the 4 complications the client is most at risk for developing.
Correct answer
A,B,C,E
Rationale
Guillain-Barr├â┬® syndrome risks include aspiration , pressure injuries , respiratory failure , and thromboembolism due to immobility and respiratory involvement.