A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech.

After having a few drinks at a local seafood restaurant, the client’s husband noticed his wife’s speech became difficult to understand.

The triage nurse does a rapid assessment of the client.

1915: Client arrives via personal car to emergency department with facial drooping and garbled speech.

Click to highlight the data that indicate the client is in need of immediate health interventions.

Choice A rationale:

Nausea can be a significant factor contributing to decreased food intake, but it is not the most likely cause in this scenario. Xerostomia (dry mouth) and mucositis are mentioned as symptoms in the question stem. Nausea alone does not explain why the client is consuming less than their body requirements.

Choice B rationale:

Fatigue can also contribute to decreased food intake, but it is not the most likely cause in this case. While fatigue can be a side effect of cancer treatment and may lead to reduced appetite, the question specifically mentions xerostomia and mucositis as issues contributing to imbalanced nutritional intake.

Choice C rationale:

Pain when eating is the most likely cause of imbalanced nutritional intake in this scenario. The client's laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the client from eating, leading to decreased nutritional intake.

Choice D rationale:

Altered taste sensation can affect food preferences, but it is not the most likely cause in this case. Pain when eating is a more direct and immediate barrier to food intake, especially in the context of mucositis and laryngeal cancer.

Choice A rationale:

The neurology unit supervisor is not the most appropriate nurse to coordinate the progression of care for a client with a spinal cord injury (SCI). While they may have expertise in neurology, the nurse case manager is specifically trained to coordinate and manage the care of patients with complex conditions, including SCI. They can facilitate communication between various healthcare providers and ensure that the client receives comprehensive care throughout their stay.

Choice B rationale:

An adult nurse practitioner may have specialized knowledge in the care of adults, but they may not have the specific skills and training required to coordinate the care of a client with a spinal cord injury in the ICU. Nurse case managers are better equipped to manage complex cases and ensure the continuity of care for the client.

Choice D rationale:

A risk management nurse focuses on minimizing healthcare-related risks and ensuring the safety of patients and staff. While their role is essential, it is not the primary responsibility to coordinate the progression of care for a client with a spinal cord injury. The nurse case manager is better suited for this role as they specialize in care coordination.