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Zorluk: OrtaEstablishing Priorities

Upon arriving for the evening shift on a neuromedical unit, a float nurse listens to the recorded handoff report. Which of the following clients must the nurse assess first?

  1. A client with myasthenia gravis who has developed a weak cough and new difficulty swallowing fluidsCevap
  2. B
    A client with Parkinson disease exhibiting a rhythmic resting tremor and pill-rolling hand movements
  3. C
    A client who had a lumbar puncture 2 hours ago and reports a headache when elevating the head of the bed
  4. D
    A client with a left-sided ischemic stroke who demonstrates frustration due to expressive aphasia

Cevap

The client with myasthenia gravis who has developed a weak cough and difficulty swallowing fluids requires immediate assessment.
The correct answer identifies a client with myasthenia gravis who is experiencing new-onset bulbar muscle weakness, evidenced by a weak cough and difficulty swallowing. This is an acute, life-threatening finding that indicates an impending myasthenic crisis and potential respiratory failure. According to the ABC (Airway, Breathing, Circulation) prioritization framework, this client's airway and breathing are at immediate risk and require emergency assessment and intervention.

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1
Analyze each client's condition to determine if the clinical findings are expected (chronic/stable) or unexpected (acute/unstable).
The myasthenia gravis client has acute, unexpected findings. The other three clients exhibit expected disease manifestations or known procedural complications.
Prioritization requires identifying which client is experiencing an acute physiological deterioration.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework to the acute findings.
The myasthenia gravis client's weak cough and dysphagia represent an immediate threat to the airway and breathing.
Airway compromise is the most critical physiological need and must always be addressed first according to the ABC framework.
3
Select the client with the most critical, life-threatening condition.
The client with myasthenia gravis is the highest priority.
Impending myasthenic crisis requires emergency assessment to prevent respiratory failure.

Anahtar Kavram

Applying the ABC (Airway, Breathing, Circulation) framework to prioritize acute neurological changes over expected chronic findings.
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Establishing Priorities

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