The nurse receives handoff of care report on four clients. Which client should the nurse assess first?

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11ecbb05_cbc7_9d53_b433_1f2a731c1303_MD0009_00 Sickle cell disease (SCD) is a group of hereditary blood disorders characterized by RBCs that become sickle-shaped, rather than oval, when deoxygenated. Sickled RBCs are prone to clump together and obstruct blood vessels, particularly during periods of dehydration or stress (eg, infection), which causes a sickle cell crisis (SCC). When caring for clients with SCD, it is critical to observe for indicators of SCC. Severe, acute pain is a common symptom of SCC due to impaired capillary blood flow (ie, vasoocclusion) and tissue ischemia. Without prompt recognition and intervention, vasoocclusion may lead to irreversible tissue damage (eg, myocardial infarction, limb necrosis, stroke) and death (Option C). (Option A) New or worsening tachycardia in clients with Graves disease, a common cause of hyperthyroidism, may be an indicator of acute thyrotoxicosis (thyroid storm). However, tachycardia can also occur normally in clients with hyperthyroidism and is less concerning in the presence of other normal vital signs. This client requires further assessment but is not the priority. (Options B and D) Administration of antibiotics (after changing the occluded catheter) and correction of hyperglycemia can be safely addressed after resolving potentially life-threatening complications. Educational objective: Severe, acute pain in clients with sickle cell disease is a common indicator of vasoocclusion and tissue ischemia from a sickle cell crisis. The nurse should immediately report signs of sickle cell crisis so that interventions may be implemented to prevent irreversible tissue damage (eg, myocardial infarction) and death.

The Nurse Receives Handoff of Care Report on Four Clients