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Difficulty: MediumEstablishing Priorities

A nurse on an infectious disease unit is reviewing the clinical status of four assigned clients. Which client requires immediate intervention by the nurse?

  1. A client with a severe soft tissue infection whose blood pressure decreased from 122/78 mmHg to 88/50 mmHg over the past two hours.Answer
  2. B
    A client with pulmonary tuberculosis who reports experiencing drenching night sweats and coughing up small amounts of blood-tinged sputum.
  3. C
    A client with viral meningitis who reports a severe headache, photophobia, and nuchal rigidity.
  4. D
    A client with lower extremity cellulitis who exhibits localized erythema, warmth, and a pain level of 6 on a 0 to 10 rating scale.

Answer

The client with a severe soft tissue infection whose blood pressure decreased significantly requires immediate intervention.
The correct answer identifies the client experiencing a sudden and significant drop in blood pressure. In the context of a severe soft tissue infection, this hypotensive trend strongly suggests the development of septic shock. Under the Airway, Breathing, and Circulation (ABC) prioritization model, establishing and maintaining adequate circulation is a life-saving priority that takes precedence over expected disease manifestations.

Step-by-Step Solution

1
Analyze each client's clinical presentation to determine if the findings are expected or unexpected for their diagnosis.
The clients with tuberculosis, meningitis, and cellulitis are exhibiting expected, stable manifestations of their respective diseases. The client with a soft tissue infection is exhibiting an unexpected, acute change in vital signs.
Prioritization requires differentiating between chronic/expected findings and acute/unexpected deteriorations.
2
Apply the Airway, Breathing, and Circulation (ABC) framework to the unexpected finding.
A blood pressure drop to 88/50 mmHg indicates a severe circulatory issue (hypotension), likely secondary to septic shock.
The ABC framework dictates that physiological needs related to survival, such as systemic circulation and perfusion, take the highest priority.

Key Concept

Prioritizing acute, unexpected circulatory complications (like shock) over expected, stable disease manifestations using the ABC framework.
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Establishing Priorities

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