Question

The nurse on the rehabilitation unit is caring for the following clients. Which client should the nurse assess first after receiving the change-of-shift report?

1. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs.
2. The client with an L4 SCI who is crying and very upset about being discharged home.
3. The client with an L2 SCI who is complaining of a headache and feeling very hot.
4. The client with a T4 SCI who is unable to move the lower extremities.

Answer 1

The nurse should assess the client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs first. Their symptoms may indicate respiratory distress or pneumonia, which requires immediate attention.

Step-by-step explanation:

The nurse on the rehabilitation unit should assess the client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs first after receiving the change-of-shift report. Dyspnea and crackles in the lungs may indicate respiratory distress or pneumonia, which can be life-threatening for a client with a spinal cord injury (SCI). Immediate assessment and appropriate intervention are necessary to ensure the client's respiratory status is stable.

The client with an L4 SCI who is crying and very upset about being discharged home may require emotional support and reassurance, but their condition is not life-threatening or requiring immediate medical attention.

The client with an L2 SCI who is complaining of a headache and feeling very hot may be experiencing a headache from various causes or may be experiencing a fever. While it is important to assess their condition, it is not as urgent as the respiratory distress in the client with the C6 SCI.

The client with a T4 SCI who is unable to move the lower extremities may require assessment and intervention, but it is not as urgent as the potential respiratory distress in the client with the C6 SCI.