The nurse is managing an assigned team. The following clients have family members reporting a concern. Which client should the nurse see first?

Question

Quizplus · Accepted Answer

Declining neurological status threatens the airway and breathing; therefore, the client with the Glasgow Coma Scale (GCS) score of 9 is the highest priority according to the ABCDs and Maslow's Hierarchy of Needs. A GCS score of 8 or lower is classified as a coma. Comatose clients are usually intubated to protect the airway ("when you are 8, intubate"). (Option A) Clients with migraine headaches have episodes of severe pain (migraine attacks). Development of new-onset headache without a known etiology would be concerning. The client with declining neurological status and a GCS score of 9 is the highest priority. (Option B) After a tonic-clonic seizure, the client wakes up gradually. It is not unusual for the client to be confused and disoriented on awakening and then to sleep for a few hours. The key concern is safety (eg, use of padded side rails, raised side rails, suction equipment in room). The nurse can teach family members the disease process and emergency care of seizures later. For now, they should encourage the client to remain in the bed with the side rails up. (Option C) Amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease) involves a progressive neurological loss of motor neurons. Typical expected symptoms are limb weakness, dysarthria (difficulty speaking), and dysphagia. Educational objective: A GCS score of 8 or less is classified as a coma. These clients are intubated for airway protection.

The Nurse Is Managing an Assigned Team