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Difficulty: MediumEstablishing Priorities

While conducting initial morning rounds on a medical-surgical neurology unit, the nurse reviews the status of several assigned clients. Which individual requires the nurse's immediate attention?

  1. A
    A client admitted yesterday with Guillain-Barré syndrome who reports that tingling has progressed from their feet to their knees.
  2. A client with myasthenia gravis who exhibits a new, distinctly muffled vocal quality and a weak cough.Answer
  3. C
    A client who sustained a mild concussion 24 hours ago and reports a persistent, dull headache rated 4 out of 10.
  4. D
    A client with Parkinson disease who is experiencing prominent resting tremors and requests assistance with eating breakfast.

Answer

The client with myasthenia gravis who exhibits a new, distinctly muffled vocal quality and a weak cough.
Applying the Airway, Breathing, Circulation (ABC) framework, the client with myasthenia gravis is the highest priority. A new, muffled voice and a weak cough indicate bulbar muscle weakness. This severely compromises the airway, limits the ability to clear secretions, and signals an impending myasthenic crisis leading to respiratory failure. Immediate intervention is required.

Step-by-Step Solution

1
Analyze each client's clinical presentation to determine if the findings are expected or unexpected for their disease process.
The clients with Guillain-Barré syndrome, a concussion, and Parkinson disease all exhibit expected, stable, or chronic findings. The client with myasthenia gravis is exhibiting a new, acute change.
Identifying acute versus chronic and unexpected versus expected findings is the first step in clinical triage.
2
Apply the Airway, Breathing, Circulation (ABC) framework to the identified acute change.
A muffled voice and weak cough indicate compromised airway protection and impending respiratory failure.
The ABC framework dictates that physiological threats to the airway and breathing take the highest clinical priority to prevent imminent mortality.

Key Concept

Prioritization Framework: Airway, Breathing, Circulation (ABCs) and Acute vs. Expected Findings
Estimated Time:1m 0s
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Topics

Establishing Priorities

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