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Zorluk: OrtaEstablishing Priorities

A home health nurse is reviewing overnight messages and scheduling the daily visitation itinerary. Based on the reported data, which client's situation warrants the first home visit of the day?

  1. A client with heart failure who reports a 3-lb (1.36 kg) weight gain over the past 24 hours and new-onset orthopnea requiring sleeping in a recliner.Cevap
  2. B
    A client with chronic obstructive pulmonary disease (COPD) whose caregiver states the client's morning sputum has become thicker and yellow.
  3. C
    A client with type 2 diabetes mellitus reporting a fasting capillary blood glucose reading of 165 mg/dL (9.16 mmol/L).
  4. D
    A client with a newly placed colostomy whose spouse expresses extreme anxiety about performing the first pouch change without supervision.

Cevap

The client with heart failure reporting a rapid weight gain and new-onset orthopnea requires the first visit.
The correct answer identifies the client experiencing acute physiological deterioration. A 3-lb weight gain in 24 hours coupled with new-onset orthopnea (difficulty breathing when lying flat) strongly suggests worsening heart failure and fluid backing up into the lungs (pulmonary edema). This is a 'Breathing' priority that requires immediate assessment and intervention to prevent respiratory failure.

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1
Analyze each client's presentation using the Airway, Breathing, Circulation (ABC) framework and Maslow's Hierarchy of Needs.
The client with heart failure has a 'Breathing' issue (orthopnea); the COPD client has a potential infection; the diabetic client has a stable, non-critical lab abnormality; the colostomy client has a psychosocial need.
Establishing priorities requires categorizing needs based on immediate physiological threats to life.
2
Compare the severity and acuity of the identified issues.
New-onset orthopnea with rapid weight gain indicates acute pulmonary edema, an unstable and potentially life-threatening breathing compromise. The other clients represent semi-urgent or stable chronic needs.
Acute, unstable conditions always take precedence over chronic, expected, or psychosocial needs.

Anahtar Kavram

Prioritization frameworks: ABCs (Airway, Breathing, Circulation) and Acute vs. Chronic
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Konular

Establishing Priorities

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