A client who is admitted for primary hypothyroidism has early signs of myxedema coma.
In assessing the client, in which sequence should the nurse complete these actions? (Rank the first action at the top with the remainder in descending order.).

The correct answer and explanation are:

A - Ask the client to describe what happened. Correct

This is the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.

Asking the client to describe what happened shows empathy, respect, and active listening, and allows the PN to gather more information and validate the client's feelings and concerns. The PN should also apologize for the delay, assess the client's pain level and needs, and provide appropriate interventions and support.

B - Inform the charge nurse of the situation.

This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.

Informing the charge nurse of the situation may be necessary, but it should be done after addressing the client's immediate needs and concerns. The PN should not ignore or avoid the client, but should communicate with him and try to resolve the issue.

C - Complete a client adverse incident report.

This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.

Completing a client adverse incident report may be required, but it should be done after addressing the client's immediate needs and concerns. The PN should not prioritize documentation over care, but should provide timely and effective pain management and support to the client.

D - Call the agency-based client advocate.

This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times. Calling the agency-based client advocate may be helpful, but it should be done after addressing the client's immediate needs and concerns.

The PN should not delegate or defer responsibility for care, but should communicate with the client and try to resolve the issue. The PN should also respect the client's right to choose whether or not to involve an advocate in his care.

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.