A nurse is evaluating the clinical status of multiple clients across different care settings. Which of the following client situations indicate an acute deterioration or safety risk requiring immediate nursing intervention? Select all that apply.
- A client with a recent femur fracture who develops sudden dyspnea and a petechial rash on the upper chest.Cevap
- A client 12 hours post-thyroidectomy who presents with an audible, high-pitched whistling sound during inspiration.Cevap
- A client with major depressive disorder who suddenly displays a cheerful, euphoric affect after weeks of profound withdrawal.Cevap
- DA client with advanced Alzheimer's disease who demonstrates increased pacing and disorientation as evening approaches.
- EA client 24 hours post-laparoscopic cholecystectomy who reports a new onset of dull right shoulder pain.
- FA client with severe chronic obstructive pulmonary disease (COPD) resting quietly with a pulse oximetry reading of 90% on room air.
Cevap
The clients requiring immediate intervention are the one with a femur fracture showing signs of fat embolism, the one post-thyroidectomy displaying stridor, and the one with major depression exhibiting a sudden, unexplained mood elevation.
The correct selections represent acute, life-threatening emergencies. Stridor indicates impending airway closure. Dyspnea with a petechial rash in a fracture patient indicates a fat embolism obstructing pulmonary circulation. A sudden, unexplained euphoric affect in a severely depressed client is a major clinical red flag for an imminent suicide attempt.
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Anahtar Kavram
Prioritization frameworks: ABCs (Airway, Breathing, Circulation), acute vs. chronic, and unexpected vs. expected findings.