A nurse has received report on four clients. What client should the nurse see first?

Ineffective Airway Clearance. This is because a client with a Glasgow Coma Scale (GCS) of 6 has a severe impairment of consciousness and is at risk of aspiration, respiratory failure, and infection. The GCS is a clinical scale that measures a person’s level of consciousness after a brain injury based on their eye, verbal and motor responses. A GCS score of 6 indicates that the client only opens eyes to pain, makes incomprehensible sounds and shows abnormal flexion to pain.

Choice A is wrong because Acute Confusion is not a priority nursing diagnosis for a client with a GCS of 6.

Acute Confusion is a state of disorientation and impaired memory that can be caused by various factors such as medication, infection, electrolyte imbalance or dementia.

A client with a GCS of 6 is not likely to be confused, but rather unresponsive or minimally responsive.

Choice B is wrong because Self-Care Deficit is not a priority nursing diagnosis for a client with a GCS of 6.

Self-care deficit is the impaired ability to perform activities of daily living such as bathing, dressing, feeding or toileting.

A client with a GCS of 6 will need assistance with all these activities, but the most urgent concern is their airway patency and oxygenation.

Choice C is wrong because Risk for Impaired Skin Integrity is not a priority nursing diagnosis for a client with a GCS of 6.

Risk for Impaired Skin Integrity is the potential for damage to the skin or underlying tissues due to pressure, friction, shear or moisture.

A client with a GCS of 6 may be at risk for developing pressure ulcers or skin breakdown due to immobility and reduced sensation, but this is not as life-threatening as ineffective airway clearance.

This is because renal calculi can cause renal colic, which is a sudden and intense pain in the flank area that radiates to the groin or testicles.

The pain is caused by the stone obstructing the ureter and triggering spasms.

Choice A is wrong because a feeling of pressure in the bladder is more likely to indicate a lower urinary tract infection or an overactive bladder.

Choice B is wrong because a mild, burning pain when urinating is more likely to indicate a urinary tract infection or a urethral injury.

Choice D is wrong because a constant, dull, aching pain in the right upper quadrant is more likely to indicate a liver or gallbladder problem.

Normal ranges for urine pH are 4.5 to 8.0, and for specific gravity are 1.005 to 1.030.