A new nurse is having a difficult time identifying which client should be seen first because they all seem important. The nurse preceptor helps and explains that the client with which of the following should be seen first?

Hypotension, tachycardia, and lethargy

Dizziness with headache 7/10 on numeric scale

Abdominal pain, hypertensive, and constipated

Febrile, tachycardia, and vomiting

Answer and Explanation

The Correct Answer is A

Choice A reason:

Hypotension (low blood pressure), tachycardia (rapid heart rate), and lethargy are critical symptoms that can indicate a life-threatening condition such as shock or severe dehydration. Hypotension can lead to inadequate perfusion of vital organs, resulting in multi-organ failure if not promptly addressed1. Tachycardia is often a compensatory mechanism for hypotension, and lethargy indicates decreased cerebral perfusion. Immediate intervention is required to stabilize the patient’s condition and prevent further deterioration.

Choice B reason:

Dizziness with a headache rated 7/10 on the numeric scale is concerning but not immediately life-threatening. These symptoms could indicate a variety of conditions, such as migraine, vertigo, or even a mild concussion. While the patient should be assessed and treated, they do not present the same immediate risk as hypotension and tachycardia.

Choice C reason:

Abdominal pain, hypertension (high blood pressure), and constipation are symptoms that need medical attention but are not immediately life-threatening. Hypertension can lead to serious complications if left untreated, but it does not require the same urgent intervention as hypotension. Abdominal pain and constipation, while uncomfortable and potentially indicative of underlying issues, do not pose an immediate threat to life.

Choice D reason:

Febrile (fever), tachycardia, and vomiting are symptoms that suggest an infection or other acute illness. While these symptoms are concerning and need prompt evaluation, they do not pose the same immediate risk as hypotension and tachycardia. Fever and vomiting can lead to dehydration, but this typically develops over a longer period compared to the rapid deterioration seen with hypotension.

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Correct Answer is A

Explanation

Choice A: He is NPO until the speech-language pathologist performs a swallowing evaluation.

When a client is admitted with a stroke, especially one affecting the left side, there is a significant risk of dysphagia, or difficulty swallowing. This can lead to choking and aspiration, which can cause pneumonia and other complications. Therefore, it is crucial to keep the client NPO (nothing by mouth) until a speech-language pathologist can perform a thorough swallowing evaluation. This ensures that the client can safely swallow without the risk of aspiration. The speech-language pathologist will assess the client’s ability to swallow different textures and consistencies of food and liquids and provide recommendations for safe feeding.

Choice B: Be sure to sit him up when you are feeding him to make him feel more natural.

While sitting the client up during feeding is a good practice to reduce the risk of aspiration, it is not sufficient on its own for a client who has just had a stroke. Without a proper swallowing evaluation, feeding the client could still pose a significant risk. Therefore, this choice is not the most appropriate response.

Choice C: You may give him a full-liquid diet, but please avoid solid foods until he gets stronger.

A full-liquid diet might seem like a safer option, but it still poses a risk of aspiration if the client has dysphagia. Without a swallowing evaluation, it is not safe to assume that the client can handle even a full-liquid diet. Therefore, this choice is not appropriate.

Choice D: Just be sure to add some thickener in his liquids to prevent choking and aspiration.

Adding thickener to liquids can help some clients with dysphagia, but it is not a one-size-fits-all solution. The appropriate consistency of liquids should be determined by a speech-language pathologist after a swallowing evaluation. Therefore, this choice is not appropriate without a prior assessment.

A. Client who displays plantar flexion when the bottom of the foot is stroked. B. Client who consistently demonstrates decortication when stimulated. C. Client whose Glasgow Coma Scale (GCS) has changed from 15 to 12. D. Client whose deep tendon reflexes have become hyperactive.

Correct Answer is C

Explanation

Choice A Reason:

The client who displays plantar flexion when the bottom of the foot is stroked is exhibiting a normal reflex response known as the plantar reflex. This response indicates that the corticospinal tract is functioning properly. In adults, the normal response is plantar flexion of the toes, which means the toes curl downward. This is not an immediate cause for concern and does not indicate a life-threatening condition.

Choice B Reason:

The client who consistently demonstrates decortication when stimulated is showing signs of severe brain injury. Decorticate posturing is characterized by the arms being flexed at the elbows and held tightly to the chest, with the legs extended and feet turned inward. This type of posturing indicates damage to the cerebral hemispheres, thalamus, or midbrain. While this is a serious condition, it is not necessarily the most immediate priority compared to a sudden change in the Glasgow Coma Scale.

Choice C Reason:

The client whose Glasgow Coma Scale (GCS) has changed from 15 to 12 is the nurse’s first priority. The GCS is a critical tool used to assess a patient’s level of consciousness, with scores ranging from 3 (deep coma) to 15 (fully awake and alert). A drop in GCS score indicates a significant decline in neurological function, which could be due to increased intracranial pressure, bleeding, or other acute changes in the brain. This requires immediate assessment and intervention to prevent further deterioration.

Choice D Reason:

The client whose deep tendon reflexes have become hyperactive is showing signs of hyperreflexia. Hyperactive reflexes can indicate an upper motor neuron lesion, which affects the descending corticospinal tract. While this is a concerning sign that warrants further investigation, it is not as immediately critical as a sudden change in the GCS score.

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A new nurse is having a difficult time identifying which client should be seen first because they all seem important. The nurse preceptor helps and explains that the client with which of the following should be seen first?

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