A nurse is caring for four clients. Which of the following should the nurse assess first?
A.
A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness
B.
A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL
C.
A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0 to 10
D.
A client who is 3 days postoperative following abdominal surgery and is ready for discharge
The Correct Answer and Explanation is:
In the scenario provided, the nurse should assess the client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness first. This is option A.
Explanation:
A. A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness
Restlessness in a client with Alzheimer’s disease who also has bacterial pneumonia is a significant concern. In patients with dementia, any change in behavior, such as increased restlessness, could indicate a worsening of their condition or a complication. In this case, the restlessness may be a sign of worsening pneumonia or other acute issues such as hypoxia, sepsis, or confusion secondary to the infection. Pneumonia can rapidly progress and lead to serious complications, especially in individuals with compromised cognitive function. Therefore, this patient’s new symptom warrants immediate assessment to rule out any severe underlying issues and to initiate appropriate interventions.
B. A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL
A fasting blood glucose level of 200 mg/dL in a newly admitted diabetic patient is elevated, but this level alone is not immediately life-threatening. It is important to manage blood glucose levels in diabetic patients, but unless there are additional symptoms of hyperglycemia (such as severe polyuria, polydipsia, or signs of diabetic ketoacidosis), this issue is less urgent compared to the risk of complications from pneumonia.
C. A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0 to 10
Postoperative pain management is crucial, and a pain level of 7 indicates significant discomfort. However, pain, while needing management, is typically not as immediately life-threatening as a potential acute complication of an infection. Pain should be managed promptly, but it does not usually require immediate assessment in the context of more severe potential complications.
D. A client who is 3 days postoperative following abdominal surgery and is ready for discharge
Being ready for discharge indicates that the client’s condition is stable and that they have progressed well enough to leave the hospital. While discharge planning is important, it is not as urgent as assessing a potentially deteriorating patient with an infection and cognitive impairment.
In summary, assessing the client with Alzheimer’s disease and bacterial pneumonia who is experiencing new restlessness is crucial due to the potential for rapid deterioration and serious complications from pneumonia.