A nurse receives report on four clients. The nurse should first collect data about the client who has which of the following?
A.
Cellulitis accompanied by a low-grade fever
B.
A decreased level of consciousness and vomiting
C.
A pain rating of 7 on a scale from 0 to 10 after receiving analgesia 30 min ago
D.
Type 2 diabetes mellitus and a blood glucose level of 160 mg/dL
The Correct answer and Explanation is:
The correct answer is:
B. A decreased level of consciousness and vomiting
Explanation:
When prioritizing care, nurses often use the ABCs (Airway, Breathing, Circulation) of emergency care, along with the concept of “Maslow’s Hierarchy of Needs” and “the urgency of the situation.” In this scenario, the client with a decreased level of consciousness (LOC) and vomiting should be the nurse’s first priority for assessment and care.
1. Airway and Breathing (ABCs): Decreased LOC and vomiting are concerning because they can indicate compromised airway patency and breathing. A decreased LOC can affect the client’s ability to protect their airway, increasing the risk of aspiration if vomiting occurs. Aspiration of vomitus can lead to airway obstruction, aspiration pneumonia, or even respiratory failure, which are life-threatening conditions. Immediate assessment and intervention are required to ensure the client’s airway is clear and protected, and that breathing is adequate.
2. Circulation: Decreased LOC can be a sign of inadequate circulation to the brain, possibly due to shock, dehydration, or other circulatory issues. This requires prompt evaluation to determine and address the underlying cause, ensuring the client receives appropriate treatment to prevent further deterioration.
3. Neurological Status: A sudden change in LOC and vomiting could also be indicative of a neurological event, such as increased intracranial pressure (ICP), head injury, stroke, or other central nervous system disorders. These conditions require immediate assessment to prevent permanent damage or death. Monitoring and maintaining the client’s neurological status is crucial.
Comparison with Other Options:
- Option A (Cellulitis with low-grade fever): While cellulitis is a serious infection, a low-grade fever typically indicates a localized or controlled infection. This client is stable, and their condition does not present an immediate life-threatening risk.
- Option C (Pain rating of 7 after receiving analgesia): While pain management is important, and the client may need reassessment, it is not life-threatening. The priority is to first address potential airway and neurological emergencies.
- Option D (Type 2 diabetes mellitus with a blood glucose of 160 mg/dL): This blood glucose level is elevated but not critically high. The client is not in immediate danger, and their condition can be managed after attending to more urgent needs.
In conclusion, the client with decreased LOC and vomiting presents the highest immediate risk for life-threatening complications, making them the nurse’s first priority for data collection and care.