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Difficulty: Very hardEstablishing Priorities

While coordinating care on a specialized neurological telemetry unit, the registered nurse receives simultaneous updates regarding four assigned clients. Which client presentation mandates the nurse's immediate assessment?

  1. A client with Guillain-Barré syndrome who exhibits new-onset drooling and a decrease in forced vital capacity from 35 mL/kg to 12 mL/kg.Answer
  2. B
    A client 4 days post-coiling of a ruptured cerebral aneurysm with an unchanged Glasgow Coma Scale score of 9 and a blood pressure of 155/92 mmHg.
  3. C
    A client with bacterial meningitis receiving intravenous antibiotics who reports new-onset bilateral hearing loss and has a temperature of 101.4°F (38.6°C).
  4. D
    A client with trigeminal neuralgia who is pacing the room and crying due to sudden, unilateral facial pain rated 10 on a 0-10 numeric scale.

Answer

The client with Guillain-Barré syndrome who exhibits new-onset drooling and a severely decreased forced vital capacity.
The correct answer identifies a client with Guillain-Barré syndrome experiencing rapid ascending paralysis that has reached the bulbar and respiratory muscles. Drooling indicates an inability to swallow and protect the airway. A forced vital capacity (FVC) that drops below 15 mL/kg is a critical threshold indicating the respiratory muscles can no longer maintain adequate ventilation, signaling impending respiratory arrest. This is a severe, immediate threat to airway and breathing.

Step-by-Step Solution

1
Analyze each client's presentation for threats to Airway, Breathing, and Circulation (ABCs).
The client with Guillain-Barré syndrome has clinical indicators of airway compromise and respiratory failure.
Airway and breathing issues take highest priority in critical care triage.
2
Evaluate the remaining clients for expected versus unexpected findings.
The clients with the aneurysm, meningitis, and trigeminal neuralgia are exhibiting expected disease trajectories, complications, or stable baseline assessments.
Clients with expected findings or stable chronicity are a lower priority than those with acute, unexpected physiological decline.
3
Select the client requiring immediate life-saving intervention.
The client with Guillain-Barré syndrome is selected.
A forced vital capacity below 15 mL/kg combined with loss of airway protection (drooling) mandates immediate rapid response activation and intubation.

Key Concept

Prioritization: Recognizing Acute Airway and Breathing Compromise
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Establishing Priorities

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