The nurse identifies several nursing problems for an older adult client with gastroenteritis who is experiencing fever, chills, anorexia, and diarrhea.
The client has a history of a stroke with left-sided hemiplegia and is dependent on care provided by the spouse. Which problem should the nurse determine has the highest priority?

Choice A rationale
The absence of coarse crackles is not necessarily an indication that chest physiotherapy (CPT) has been effective for a client with chronic obstructive pulmonary disease (COPD). Coarse crackles are often heard in conditions where there is fluid in the airways, such as pneumonia or heart failure. While their absence might indicate that there is no fluid in the airways, it does not necessarily mean that secretions have been effectively mobilized.
Choice B rationale
An increase in breath sounds is a good indication that chest physiotherapy (CPT) has been effective for a client with COPD3. CPT is a group of therapies designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system. When these secretions are effectively mobilized and removed, breath sounds can become clearer and more easily heard.
Choice C rationale

The absence of fine crackles is not necessarily an indication that CPT has been effective for a client with COPD. Fine crackles are often heard in conditions where there is fluid in the airways or alveoli, such as pneumonia or heart failure. While their absence might indicate that there is no fluid in the airways or alveoli, it does not necessarily mean that secretions have been effectively mobilized.
Choice D rationale
An increase in respiratory rate is not necessarily an indication that CPT has been effective for a client with COPD. In fact, an increased respiratory rate could indicate respiratory distress, which could suggest that the therapy has not been effective or that the client’s condition has worsened.

Choice A rationale
While the patient’s currently prescribed medications are important information, they are not the most immediate concern in this situation. The healthcare provider will need this information, but it does not need to be the first piece of information provided.

Choice B rationale
The increasing confusion of the patient is the most immediate concern and should be communicated first. Confusion and disorientation can be signs of a serious condition such as a brain injury, especially following a fall. It is crucial to relay this information to the healthcare provider as soon as possible so that appropriate diagnostic tests can be ordered and treatment can be initiated.
Choice C rationale
The patient’s healthcare power of attorney is important information, especially if the patient’s condition worsens and they are unable to make decisions for themselves. However, this information does not need to be communicated first. The immediate concern is the patient’s medical condition.
Choice D rationale
The fall from a ladder is certainly important information as it provides context for the patient’s current condition. However, it does not need to be the first piece of information provided. The healthcare provider will likely infer that a fall has occurred based on the other information provided (e.g., confusion, potential loss of consciousness).