A registered nurse (RN) on a neurology unit is planning the sequence of care for four assigned clients. Arrange the clients in the order they should be assessed, from highest priority (first) to lowest priority (last).
- 1A client with myasthenia gravis who reports a new onset of difficulty swallowing and managing oral secretions
- 2A client who is 12 hours postoperative following a craniotomy and is reporting a severe, throbbing headache
- 3A client with Parkinson disease who is scheduled to receive a prescribed dose of levodopa-carbidopa in 15 minutes
- 4A client who had an ischemic stroke 3 days ago and is waiting for assistance to eat breakfast
Answer
The correct assessment order is: 1) the client with myasthenia gravis, 2) the client post-craniotomy, 3) the client with Parkinson disease, and 4) the stable client requiring assistance with breakfast.
Prioritization requires the nurse to evaluate each client's physiological stability and acuity. According to the ABC framework, the client with myasthenia gravis and new-onset dysphagia has a threatened airway, making them the absolute highest priority. The postoperative craniotomy client is the second priority due to the risk of increased intracranial pressure, a severe and unstable complication. The client with Parkinson disease requires time-sensitive medication administration to prevent symptom exacerbation, making them the third priority. Finally, the client recovering from a stroke simply requires assistance with routine activities of daily living, which is the lowest priority.
Step-by-Step Solution
Key Concept
Prioritization of client care based on the ABC framework and physiological stability
Estimated Time:1m 30s