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Difficulty: MediumEstablishing Priorities

A registered nurse is planning initial assessments for a group of clients on a neurological step-down unit. Which client must the nurse evaluate first?

  1. A
    A client with multiple sclerosis who reports worsening double vision and extreme fatigue.
  2. A client with myasthenia gravis who exhibits a weak, muffled voice and inability to clear oral secretions.Answer
  3. C
    A client with Parkinson disease whose family reports increased freezing episodes during ambulation.
  4. D
    A client recovering from an ischemic stroke 3 days ago who is emotionally labile and refusing therapy.

Answer

The client with myasthenia gravis exhibiting a weak, muffled voice and inability to clear secretions.
The correct answer identifies a direct threat to the client's airway. In myasthenia gravis, a muffled voice and pooling of oral secretions indicate bulbar muscle weakness. This is a hallmark warning sign of impending respiratory muscle paralysis (myasthenic crisis). According to the ABCs (Airway, Breathing, Circulation) of prioritization, this client must be seen immediately to prevent respiratory arrest.

Step-by-Step Solution

1
Analyze each client's presentation using the Airway, Breathing, Circulation (ABC) prioritization framework.
The client with myasthenia gravis has symptoms affecting the throat and mouth (bulbar weakness), directly threatening the airway.
Airway patency is the highest physiological priority. Inability to clear secretions can lead to aspiration or complete airway obstruction.
2
Compare the remaining clients to determine acute versus expected chronic findings.
The client with multiple sclerosis has acute, non-life-threatening symptoms. The client with Parkinson disease has expected chronic symptoms. The stroke client has expected psychosocial needs.
After securing the ABCs, prioritization moves to acute neurological changes over expected chronic or psychosocial issues.
3
Select the client with the highest physiological risk.
The myasthenia gravis client is selected as the first priority.
Impending myasthenic crisis requires immediate evaluation for intubation and mechanical ventilation.

Key Concept

Prioritization using the ABC (Airway, Breathing, Circulation) framework in acute neurological deterioration.
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Establishing Priorities

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