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Zorluk: KolayEstablishing Priorities

A nurse is conducting initial rounds and reviewing assessment findings for several clients on a medical-surgical unit. Which of the following client presentations require immediate intervention by the nurse? (Select all that apply.)

  1. A client with a head injury whose Glasgow Coma Scale (GCS) score has decreased from 14 to 11Cevap
  2. B
    A client with Parkinson's disease who exhibits a resting tremor in the hands and a shuffling gait
  3. A client with a recent femur fracture who develops sudden confusion and a petechial rash on the chestCevap
  4. D
    A client with multiple sclerosis who reports chronic afternoon fatigue and muscle spasticity in the lower extremities
  5. A client with pneumonia who has a new oxygen saturation reading of 87% on room air and circumoral cyanosisCevap

Cevap

The clients requiring immediate intervention are the one with a head injury and a dropping GCS score, the one with a femur fracture showing signs of fat embolism, and the one with pneumonia presenting with acute hypoxia and cyanosis.
The correct selections represent clients experiencing acute, unexpected, and potentially life-threatening physiological changes. A dropping GCS indicates rising intracranial pressure. Sudden confusion and petechiae after a bone fracture indicate a fat embolism. An oxygen saturation of 87% with cyanosis indicates acute respiratory failure. All of these require immediate emergency response.

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1
Evaluate each client's presentation to determine if the findings are expected (chronic/stable) or unexpected (acute/unstable).
Three clients have acute, unexpected, or life-threatening changes, while two have expected, chronic disease manifestations.
Prioritization requires identifying which conditions pose an immediate threat to life, typically utilizing the Airway-Breathing-Circulation (ABC) framework and acute versus chronic principles.
2
Apply prioritization frameworks to select all clients requiring immediate attention.
The GCS drop (neurological deterioration), fat embolism signs (circulation/oxygenation threat), and low oxygen saturation with cyanosis (airway/breathing threat) are identified as immediate priorities.
Clients with acute, unstable changes or ABC compromises always take precedence over clients with expected, stable, or chronic findings.

Anahtar Kavram

Prioritization: Acute vs. Chronic and Unexpected vs. Expected Findings
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Konular

Establishing Priorities

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