Patho Patho #32

Question

Which client should the nurse assess first?

Answers

  1. A client with Cushing’s syndrome who has a blood pressure of 130/90.
    • Rationale:

      This answer choice is not correct because a blood pressure of 130/90 is expected in a client with Cushing syndrome. This client is not the nurse’s priority.

  2. A client with hypothyroidism who is asking for PO pain medicine for a mild headache.
    • Rationale:

      This answer choice is not correct because a client with hypothyroidism is stable and is not the nurse’s priority for assessment.

  3. A client with hyperosmolar hyperglycemic non-ketosis (HHNK) who has a blood pressure of 78/48.
    • Rationale:

      This answer is correct because a client with HHNK who has a blood pressure of 78/48 is displaying signs/symptoms of hypovolemia. Hypovolemia is the most important cause of mortality in clients with HHNK and this client should therefore be immediately assessed by the nurse and evaluated for further intervention.

  4. A client with Grave’s disease who reportedly has “bulging eyes”.
    • Rationale:

      This answer choice is not correct because a client with Grave disease is expected to have bulging eyes which is referred to as exophthalmos. This client is not the nurse’s priority.

Overview

The focus of this question is asking the nurse to prioritize the most critical of a group of four clients. The most critical client in this group is the hypotensive client with hyperosmolar hyperglycemic non-ketosis. Hypovolemia is the most important cause of mortality in clients with HHNK. The other three clients are experiencing expected manifestations associated with their respective diagnoses.

Explanation

Learning Outcomes

When addressing client need prioritization, always apply A-B-C. None of the above clients have airway or breathing issues, however the hypotensive client with HHNK is experiencing circulation issues. Hypovolemia and dehydration is the most important cause of mortality in clients with HHNK and therefore this client is the nurse’s priority.

Test Taking Tip

A-B-C

Video Rationale