Question

A client arrives at the emergency department experiencing tingling and weakness in the lower extremities that started when getting out of bed. The client reports the symptoms seem to be progressing upward. Which statement by the client is most important for the nurse to pursue during the assessment process?1. "My grandfather had polio when he was young."2. "I have been a vegetarian for several months now."3. "Things have been stressful at work lately."4. "We have been in the final preparations for a trip overseas."

Answer 1

4. We have been in the final preparation for a trip overseas- CORRECT

Step-by-step explanation:

The information or statement that should be taken as most important will depend on relatedness, severity and possible degeneration.

Option 4 is correct because immunizations are usually given when preparing for oversea trips and the danger is that immunizations are possible triggers of the onset of the neurological symptoms of Guillain Barre syndrome.

A critical issue is that this requires further investigation because, the symptoms of the syndrome can rapidly progress. Furthermore, since it is progressing upward (which is not usually the case), it becomes an emergency case that should be treated urgently.

The greatest concern of the nurse should be to prevent respiratory compromise that may result from muscle weakness of the respiratory system

Note: Guillain Barre syndrome represents autoimmune disease that will usually affect areas such as swallowing, speech, facial expression and respiration.