Patho Patho #65

Question

Which client would the nurse assess first?

Answers

  1. An elderly client with Parkinson’s who is confused to time.
    • Rationale:

      This answer choice is not correct as confusion to time is not a critical finding in a client with Parkinson.

  2. A 48 year old client admitted with a transient ischemic attack 3 days ago.
    • Rationale:

      This answer choice is not correct as a client who experienced a transient ischemic attack (TIA) 3 days prior is not the most critically ill client. The client will need to be monitored for manifestations of another TIA or stroke, but a client with a possible ruptured cerebral aneurysm is the most critical client.

  3. A client with uncontrolled hypertension who states he has “the worst headache of his life”.
    • Rationale:

      This answer is correct because a client with a history of uncontrolled hypertension is at increased risk for a cerebral aneurysm. Reports of a severe headache could indicate that the aneurysm has ruptured and this client requires immediate assessment by the nurse.

  4. “A client with a closed head injury with a recent intracranial pressure reading of 7 mmHg.”
    • Rationale:

      This answer choice is not correct because an intracranial pressure of 7 mmHg is within normal limits and is adequate to maintain cerebral perfusion.

Overview

The focus of this question is prioritization. The nurse is asked to choose from a group of 4 clients who is the most critical and requires the nurse’s immediate attention. A client with a history of uncontrolled hypertension who is reporting a severe headache is concerning due to the possible comp;lication of a ruptured cerebral aneurysm.

Explanation

Learning Outcomes

Prioritization questions are common on nursing exams and NCLEX. The nurse must assess a group of clients and determine who is the most acutely ill requiring immediate assessment and/ or intervention. The most classic presentation of a ruptured cerebral aneurysm is the report of “the worst headache” a client has ever experienced. This client should be assessed immediately for additional manifestations of this life-threatening complication.

Test Taking Tip

All clients with severe, prolonged, poorly controlled hypertension are at risk for development of aneurysms. The nurse must know the most classic presentations of each type of aneurysm and signs of aneurysm rupture.

Video Rationale