Difficulty: Medium
Average Score: 87%
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.
1830:
Client is experiencing tachycardia, productive cough, and confusion
The client is at risk for ________ as evidenced by __________. Complete the following sentence by using the list of options.
Correct answer
A,D
Rationale
The client with paraplegia, cough, and reduced appetite is at risk for hypostatic pneumonia due to immobility, which impairs lung clearance and increases infection risk. Anemia, fluid overload, and calorie deficiency are not directly supported by the symptoms.