The nursing team has just concluded the morning shift handover. Upon reviewing the client profiles, which of the following clinical presentations necessitate an immediate priority assessment? Select all that apply.
- A client 2 hours post-total thyroidectomy who reports new-onset numbness and tingling around the lips.Cevap
- A client admitted 12 hours ago with a fractured femur who suddenly develops confusion and an oxygen saturation of 88% on room air.Cevap
- CA client with severe chronic obstructive pulmonary disease (COPD) who has a barrel chest and an oxygen saturation of 90% on room air.
- DA client 24 hours post-laparoscopic cholecystectomy who reports right shoulder pain rated 4 on a 0 to 10 scale.
- EA client with a mild concussion admitted overnight who is easily arousable and reports a persistent dull headache.
Cevap
The clients requiring immediate priority assessment are the one reporting numbness around the lips post-thyroidectomy and the one with a femur fracture developing confusion and hypoxia.
The correct selections involve clients experiencing acute, life-threatening complications related to airway and breathing. The post-thyroidectomy client is showing signs of hypocalcemia (circumoral paresthesia), which places them at immediate risk for laryngospasm and airway loss. The client with a femur fracture is exhibiting classic signs of fat embolism syndrome (sudden hypoxia and confusion), which is a critical respiratory emergency.
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Anahtar Kavram
When establishing priorities, the nurse must rapidly identify acute, unexpected findings that threaten airway, breathing, or circulation (ABCs) over chronic, expected, or stable manifestations.