Management of Care Q 35
After receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first?
A. A 23-year-old with a migraine headache who is complaining of severe nausea associated with retching.
B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching.
C. A 59-year-old with Parkinson’s disease who will need a swallowing assessment before breakfast.
D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain.
Correct Answer: D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain.
Urinary tract infections are a frequent complication in patients with multiple sclerosis because of the effect on bladder function. The elevated temperature and decreased breath sounds suggest that this patient may have pyelonephritis. The physician should be notified immediately so that antibiotic therapy can be started quickly.
Option A: This patient needs further assessment, but does not require immediate attention. A migraine can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It’s often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with daily activities.
Option B: Preoperative teaching must be done but it is not the nurse’s priority. A craniotomy is the surgical removal of part of the bone from the skull to expose the brain. Specialized tools are used to remove the section of bone called the bone flap. The bone flap is temporarily removed, then replaced after the brain surgery has been done.
Option C: The patient should be assessed soon, but does not have an urgent need. In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of the nerves.