Management of Care Q 18
When prioritizing care, which of the following clients should the nurse Olivia assess first?
A. A 17-year-old client 24-hours post appendectomy.
B. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome.
C. A 50-year-old client 3 days post myocardial infarction.
D. A 50-year-old client with diverticulitis.
Correct Answer: B. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome
Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorder of airways, breathing, and then circulation.
Option A: The client who is post appendectomy has no signs of hemorrhage or unstable vital signs. Possible complications of appendectomy are bleeding, wound infection, peritonitis, blocked bowels, and injury to nearby organs.
Option C: There’s no information to suggest the postmyocardial infarction client has an arrhythmia or other complication. About 90% of patients who have an acute MI develop some form of cardiac arrhythmia during or immediately after the event.
Option D: There’s no evidence to suggest perforation for the client with diverticulitis as a priority of care. Diverticula are small, bulging pouches that can form in the lining of the digestive system.when one or more of the pouches become inflamed, and in some cases infected, that condition is known as diverticulitis.