Difficulty: Medium
Average Score: 82%
Simulated
Passage / Scenario
Nurses' NotesVital Signs
Diagnostic Results
Day 1
1400:
Client has paraplegia and reports, "I have had a cough the last few days. I haven't had an appetite either." Denies nausea, vomiting, or diarrhea. Alert and oriented to person, place, and time. Skin is intact. Vital signs stable.
Day 2 1830:
Client is experiencing tachycardia, productive cough, and confusion
Complete the following sentence by using the list of options. The client is at risk for ___ as evidenced by ___ .
Correct answer
A
Rationale
The client is at risk for hypostatic pneumonia as evidenced by immobility. Immobility increases the risk of lung fluid accumulation.