Patho Patho #76

Question

Which client should the nurse assess first?

Answers

  1. A client with DKA who has a current blood glucose of 300 mg/dL
    • Rationale:

      This answer choice is not correct because in a client with DKA, a blood glucose of 300 mg/dL is not critically high. This client is not the nurse’s highest priority.

  2. A client with hypoparathyroidism who is reporting dyspnea.
    • Rationale:

      This answer is correct because a client with hypoparathyroidism reporting dyspnea may be experiencing laryngeal spasms. This client requires immediate assessment by the nurse.

  3. A client with hypothyroidism with a current heart rate of 60 BPM.
    • Rationale:

      This answer choice is not correct because a decreased heart rate is expected in clients with hypothyroidism. This client is not the nurse’s highest priority.

  4. A client with syndrome of inappropriate diuretic hormone with peripheral edema.
    • Rationale:

      This answer choice is not correct because a client with syndrome of inappropriate antidiuretic hormone is expected to have peripheral edema. This client is the nurse’s lowest priority.

Overview

The focus of this question is asking the nurse to determine which client is the most critically ill and requires immediate assessment. A client with hypoparathyroidism is at risk for hypocalcemia because parathyroid hormone stimulates calcium production. The most dangerous potential complication of hypocalcemia is laryngeal spasms, therefore the client with hypoparathyroidism reporting dyspnea should be assessed first.

Explanation

Learning Outcomes

Hypoparathyroidism results in underproduction of parathyroid hormone by the parathyroid glands. Parathyroid hormone is largely responsible for stimulation of calcium production. In clients with hypoparathyroidism, hypocalcemia is common. Severe hypocalcemia can lead to laryngeal spasms, leading the client to experience dyspnea. This is a very serious potential complication of hypoparathyroidism and this client should be assessed first by the nurse.

Test Taking Tip

A-B-C

Video Rationale