Examkin

Question

Difficulty: MediumEstablishing Priorities

During a shift on a specialized orthopedic trauma unit, a nurse evaluates the clinical status of several clients. Which client presentation dictates the need for the most immediate clinical intervention?

  1. A client with a closed pelvic fracture who is exhibiting new-onset restlessness and a heart rate of 118 beats/min.Answer
  2. B
    A client 24 hours post-spinal fusion who has a temperature of 99.8°F (37.7°C) and requests analgesic medication for incisional pain.
  3. C
    A client in skeletal traction for a femur fracture who is experiencing intermittent muscle spasms in the affected limb.
  4. D
    A client with a newly applied long-arm cast whose fingers are warm to the touch with a capillary refill time of 2 seconds.

Answer

The client with a closed pelvic fracture who is exhibiting new-onset restlessness and a heart rate of 118 beats/min.
The client with a pelvic fracture is exhibiting restlessness and tachycardia, which are classic early signs of hypovolemic shock. Because the pelvis is highly vascular, fractures in this area can cause massive occult internal bleeding. According to the ABCs (Airway, Breathing, Circulation) framework, establishing hemodynamic stability for this client is the most urgent clinical priority.

Step-by-Step Solution

1
Analyze the clinical presentation of each client to differentiate between expected post-injury/postoperative findings and acute deterioration.
Three clients have stable or expected findings (mild fever, spasms, normal capillary refill), while one client has signs of a potential systemic complication (restlessness, tachycardia).
Prioritization requires identifying the client with the most unstable or life-threatening condition.
2
Apply the ABC (Airway, Breathing, Circulation) prioritization framework to the most unstable client.
The client with a pelvic fracture demonstrates acute circulatory compromise (tachycardia) and altered cerebral perfusion (restlessness).
The ABC framework dictates that circulatory emergencies, such as impending hypovolemic shock from a highly vascular pelvic fracture, take absolute precedence over expected postoperative symptoms.

Key Concept

Prioritization using the ABCs (Airway, Breathing, Circulation) framework to identify early signs of hypovolemic shock in high-risk trauma clients.
Rate this question

Topics

Establishing Priorities

More questions from this topic