A nurse is performing change of shift assessments for four clients. Which of the following findings should the nurse prioritize?
A.
A client who has gastroenteritis and is lethargic and confused
B.
A client who has cystic fibrosis, has a thick, productive cough, and reports thirst
C.
A client who has sickle cell anemia and reports pain 15 minutes after receiving oral analgesic
D.
A client who has diabetes mellitus and has a morning fasting capillary glucose of 185 mg/dL
The Correct Answer and Explanation is:
In this scenario, the nurse should prioritize the assessment of A. A client who has gastroenteritis and is lethargic and confused.
Here’s why this finding is the most critical:
Explanation:
A. Lethargic and Confused Client with Gastroenteritis:
- Clinical Significance: Lethargy and confusion in a client with gastroenteritis are concerning symptoms. Gastroenteritis, often caused by a viral or bacterial infection, can lead to severe dehydration, especially if the client is experiencing significant vomiting and diarrhea. Dehydration can cause or exacerbate altered mental status, including lethargy and confusion.
- Potential Complications: Severe dehydration can lead to electrolyte imbalances, kidney dysfunction, and even shock. If not addressed promptly, these complications can rapidly deteriorate the client’s condition. Confusion and lethargy might indicate an advanced state of dehydration or an underlying infection that is not being managed effectively.
- Prioritization: Assessing this client first allows for immediate intervention to address dehydration and prevent further complications. Interventions might include intravenous fluid replacement, electrolyte monitoring, and appropriate medication administration.
B. Client with Cystic Fibrosis:
- Clinical Significance: While the client with cystic fibrosis and a thick, productive cough is experiencing symptoms that could indicate a respiratory infection or worsening pulmonary function, thirst alone isn’t as acute a concern compared to the lethargy and confusion seen in the gastroenteritis patient.
- Management: Though important, this client’s condition, although chronic, typically involves longer-term management and monitoring.
C. Client with Sickle Cell Anemia:
- Clinical Significance: Pain following oral analgesic administration in sickle cell anemia is a common issue. It’s important to monitor pain levels and efficacy of pain management, but this situation might not be as immediately life-threatening compared to altered mental status from possible dehydration or shock.
D. Client with Diabetes Mellitus:
- Clinical Significance: A fasting capillary glucose level of 185 mg/dL is elevated, indicating hyperglycemia. However, this finding is less critical in an acute sense compared to the potential for severe dehydration and altered mental status in the client with gastroenteritis.
In summary, the client with gastroenteritis who is lethargic and confused presents with potentially life-threatening symptoms that require immediate attention to prevent severe complications. The priority should be to stabilize this client’s condition and ensure adequate hydration and electrolyte balance.