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Difficulty: MediumPhysiological Adaptation

Following change-of-shift report on a medical-surgical step-down unit, which of the following assigned clients must the nurse assess first?

  1. A client with syndrome of inappropriate antidiuretic hormone whose serum sodium level dropped from 127 mEq/L to 114 mEq/L and who exhibits progressive lethargy.Answer
  2. B
    A client treated for an asthma exacerbation whose arterial blood gas values reveal a pH of 7.38, a PaCO2 of 41 mm Hg, and a PaO2 of 94 mm Hg.
  3. C
    A client receiving intravenous hydration for profound dehydration whose pulse pressure widened from 22 mm Hg to 40 mm Hg over the last four hours.
  4. D
    A client recovering from a total hip arthroplasty who is resting supine with an abduction wedge in place and reports an ache at the surgical site.

Answer

The client with syndrome of inappropriate antidiuretic hormone (SIADH) experiencing a severe sodium drop and lethargy must be assessed first.
The client with syndrome of inappropriate antidiuretic hormone is exhibiting a severe, acute drop in serum sodium to a critical level (114 mEq/L), accompanied by neurological decline (progressive lethargy). This presentation strongly indicates the development of cerebral edema due to intracellular fluid shifts. This is a life-threatening medical emergency requiring immediate assessment and intervention (such as hypertonic saline administration) to prevent seizures, coma, or brain herniation.

Step-by-Step Solution

1
Analyze the client with SIADH for physiological instability.
The client has critical hyponatremia (114 mEq/L) and new neurological symptoms (lethargy).
Serum sodium below 120 mEq/L causes severe fluid shifts into brain cells, leading to cerebral edema, seizures, and potential brainstem herniation.
2
Evaluate the asthma client's arterial blood gas values.
Values (pH 7.38, PaCO2 41, PaO2 94) are completely normal.
Normal ABGs indicate the asthma exacerbation is resolving and the airway is currently stable.
3
Interpret the hemodynamic trend for the dehydrated client.
Pulse pressure improved from a narrow 22 mm Hg to a normal 40 mm Hg.
A narrow pulse pressure indicates compensatory shock. Widening to 40 mm Hg signifies successful fluid resuscitation.
4
Assess the post-operative orthopedic client's status.
The client is in the correct position with expected postoperative pain.
An abduction wedge prevents adduction and subsequent hip dislocation, indicating safe and appropriate care.
5
Compare the acuity of all four clients to establish priority.
The SIADH client is the only one experiencing an acute, life-threatening physiological deterioration.
Using the ABCs and Maslow's hierarchy, an impending neurological crisis from severe electrolyte imbalance takes highest priority.

Key Concept

Prioritization of Acute Neurological Complications in Electrolyte Imbalances
Estimated Time:1m 15s
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Topics

Physiological Adaptation

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