Reference no: EM133344487

Case Study: The client is a 64-year-old man who was brought to the emergency department by his wife who claims he is "just not acting right." When asked to elaborate, the wife explains that over the past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now does not recognize the neighbor who has been coming over daily for a short visit. The wife further explains that her husband is a nuclear physicist.

On Assessment, the nurse finds the client somewhat responsive to his name, although he does not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial drooping but appears too confused to stick out his tongue when asked or try to shrug his shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day. Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily for about 4 weeks for his back pain. He stopped taking the drug and went back to work on Monday (today is Sunday) because he was pain free.

Questions:

(1) What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to determine what is most important.)
(2) What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.)
(3) Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.)
(4) Which actions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.)