Question

You are the RN working on a surgical unit, and you are assigned the following four clients: A. A 62-year old male with a history of COPD and CHF, who had a cholecystectomy B. A 28-year old female with a head injury from a motorcycle accident who had burr hole surgery C. A 43-year old female with controlled AFib who has a broken right leg from falling off a horse D. A 62-year old college professor who had a stroke while playing tennis Their surgeries were all unremarkable, and they are all 1-day postoperative. You heard the following updates in change-of-shift report this morning: A. 02 sat 92% on 2L, lung sounds diminished bilaterally, non-productive cough B. Persistent confusion and slight restlessness, moves all extremities C. Pain level is 8/10, up from 5/10 last night. Right pedal pulses weak, right foot swollen. D. Complaining of headache at 10/10, unrelieved by pain medication. Questions: 1. Which of these clients should the nurse see first? Explain your answer. 2. What other information is needed (if any) to make your decision? 3. Use the Nightingale library and the CINAHL search system to find an article from a peer-reviewed journal published in the last 5 that supports the priorities of nursing care you identified. 4. In your peer replies, compare your order of priority with your classmates’ order and discuss differences.

Answer 1

1) Stroke is defined as any interruption of blood supply to the brain cells. It occurs due to Blockage of the cerebral blood flow or by rupture of the blood vessels. Out of 4 scenario Option D needs high priority . Complaining of severe headache rates as 10/10 in a pain scale and it's not responding to pain killer. In stroke elevated intracranial pressure is noticed secondary to thromboembolic clots. Elevated ICP secondary to stroke is a medical emergency.

2) Other information like a comprehensive Physical examination is done to assess the associated symptoms related to elevated ICP like blurred vision ,behavior changes ,

slurred Speech, disorientation, propulsive vomiting, loss of consciousness.

Other options A,B,C has moderate priority as the condition of the client is stable and it's not life-threatening seeking emergency care.