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Question

Difficulty: MediumEstablishing Priorities

A nurse on a neurological and trauma step-down unit is evaluating the clinical status of multiple assigned clients. Which client presentation requires the nurse's immediate intervention?

  1. A client with a T4 spinal cord injury who reports a sudden, throbbing headache and exhibits profound diaphoresis.Answer
  2. B
    A client admitted 48 hours ago with an ischemic stroke who demonstrates persistent expressive aphasia.
  3. C
    A client with a chest tube for a traumatic hemothorax that has drained 45 mL of dark red fluid over the past hour.
  4. D
    A client with a stable pelvic fracture who requests assistance with repositioning due to muscle stiffness.

Answer

The client with a T4 spinal cord injury reporting a sudden, throbbing headache and profound diaphoresis must be seen first.
The client with a T4 spinal cord injury is exhibiting classic signs of autonomic dysreflexia, a life-threatening medical emergency triggered by a noxious stimulus below the level of the spinal injury. This causes a massive sympathetic nervous system discharge resulting in severe hypertension. Without immediate intervention, such as elevating the head of the bed and removing the stimulus, the client is at imminent risk for seizures, stroke, and death. This represents an acute, unstable condition that dictates immediate priority.

Step-by-Step Solution

1
Evaluate the clinical acuity and stability of each client's presentation.
Identify which symptoms represent expected, chronic, or stable findings versus acute, life-threatening complications.
Safe prioritization requires the nurse to immediately address clients with new physiological instability or threats to airway, breathing, and circulation.
2
Analyze the symptoms of the client with the spinal cord injury.
Recognize that a severe headache, diaphoresis, and a T4 injury indicate autonomic dysreflexia.
Autonomic dysreflexia is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system that constitutes a hypertensive emergency.
3
Compare the urgency of autonomic dysreflexia against the other client presentations.
Determine that the stroke deficits, chest tube drainage volume, and muscle stiffness are all stable, non-emergent findings.
Acute, unstable, and rapidly deteriorating conditions must always be prioritized over chronic or expected physiological states.

Key Concept

Prioritizing Care for Acute Neurological Emergencies
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Topics

Establishing Priorities

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