The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

Choice A reason: Hyperactive reflexes suggest neurological irritability but are less urgent than a GCS drop from 15 to 10, indicating deteriorating consciousness. This is incorrect, as it’s lower priority than the nurse’s focus on a client with a significant neurological decline.

Choice B reason: Plantar flexion (Babinski sign) may indicate neurological issues, but a GCS drop to 10 signals acute deterioration, requiring immediate attention. This is incorrect, as it’s less critical than the nurse’s priority to assess the client with a declining GCS.

Choice C reason: Decortication indicates severe brain injury but, if consistent, is less acute than a GCS drop from 15 to 10, suggesting rapid worsening. This is incorrect, as it’s not the nurse’s first priority compared to the client with acute neurological change.

Choice D reason: A GCS drop from 15 to 10 indicates a significant decline in consciousness, a neurological emergency requiring immediate assessment. This aligns with neurosurgical priorities, making it the correct client for the nurse to prioritize on the unit.

Choice A reason: Sodium of 130 mEq/L indicates hyponatremia, likely from vomiting-induced sodium loss. This aligns with the child’s electrolyte profile and symptoms, making it a correct imbalance the nurse would identify as most likely based on the lab values and clinical presentation.

Choice B reason: Calcium of 9.5 mg/dL is normal, not indicating hypocalcemia. Hyponatremia and metabolic alkalosis match the labs (sodium 130, HCO3 30), making this incorrect, as it does not reflect the child’s electrolyte imbalances from vomiting and irregular pulse.

Choice C reason: Potassium of 3.3 mEq/L is low, not high, ruling out hyperkalemia. Hyponatremia and metabolic alkalosis fit the labs and vomiting history, making this incorrect, as it contradicts the child’s potassium level in the nurse’s assessment of imbalances.

Choice D reason: Potassium of 3.3 mEq/L suggests mild hypokalemia, but hyponatremia (sodium 130) is more prominent with vomiting. Metabolic alkalosis is also evident, making this partially correct but incorrect as the primary imbalance compared to hyponatremia in the child’s profile.

Choice E reason: HCO3 of 30 mEq/L indicates alkalosis, not acidosis, due to vomiting-induced hydrogen ion loss. Hyponatremia and metabolic alkalosis are correct, making this incorrect, as it contradicts the child’s alkalotic state in the nurse’s evaluation of lab values.

Choice F reason: HCO3 of 30 mEq/L indicates metabolic alkalosis, common with vomiting due to loss of acidic gastric contents. This, with hyponatremia, aligns with the child’s labs and symptoms, making it a correct imbalance the nurse would identify in the assessment.