The nurse has received report on 4 clients at the start of the shift. Which client should the nurse assess first?

Question

Quizplus · Accepted Answer

Clients with large body casts are at risk for bowel obstruction, which can be caused by decreased peristalsis or by cast syndrome (ie, superior mesenteric artery [SMA] syndrome). Cast syndrome is a rare complication of an overly tight cast that involves compression of the duodenum by the SMA. Immobilization of clients in body casts decreases peristalsis and may cause a paralytic ileus (ie, bowel obstruction). If severe, bowel obstruction can result in bowel ischemia. The nurse should immediately report symptoms of a bowel obstruction (eg, abdominal pain, distension, nausea, vomiting) (Option A). If cast syndrome is suspected, the cast may have a window cut out over the abdomen to relieve pressure. (Option B) After a mastectomy, tingling, numbness, and itching are common at the incision site. A client experiencing this likely requires reassurance, but this is a lower priority. (Option C) Chewing may be difficult after a neck dissection due to tissue trauma. A client experiencing this may require a diet change, but this is a lower priority. (Option D) Antibiotics disrupt normal vaginal flora and may precipitate the development of a yeast infection, which presents with vaginal discharge and itching. A client reporting this needs to be assessed, but this is a lower priority. Educational objective: Large body casts can cause bowel obstruction as a result of cast syndrome or decreased peristalsis. Bowel obstruction symptoms should be addressed immediately due to the potential for bowel ischemia.

The Nurse Has Received Report on 4 Clients at the Start