Which nursing action has the highest priority when preparing to transfer an unconscious client

Respiratory Exchange
- Ascending paralysis can reach the diaphragm, leading to death from respiratory failure.

More on GB:
Motor manifestations affecting mobility
- ascending symmetric muscle weakness--> flaccid paralysis without muscle atrophy
- decreased or absent DTRs
- Respiratory compromise (dyspnea, diminished breath sounds, decreased tidal volume, reduced peripheral oxygenation and vital capacity, and respiratory failure
- loss of bowel and bladder control (less common)
- Ataxia

Sensory Perception manifestations: Paresthesias and pain (cramping)

CN manifestations: Facial weakness, dysphagia, diplopia, difficulty speaking

Autonomic manifestations: Labile BP, cardiac dysrhythmias, tachycardia

Which factor would the nurse consider when setting priorities for care during a shift?

When setting priorities for care, the nurse must consider client acuity, organization of the unit, assessment of available resources, recognition of own experience and expertise, and an understanding of care philosophies and models of care used on the unit.

Which intervention is most important for the nurse to include in the plan of care for a client with ankylosing spondylitis?

Upper right abdominal pain that occurs after meals and radiates to the back or right shoulder. Which intervention is most important for the nurse to include in the plan of care for a client with ankylosing spondylitis? Initiate a smoking cessation program.

Which of the following clients should the nurse attend to first?

Which of the following actions should the nurse take first? Monitor the client's vital signs. -The greatest risk to this client is injury from receiving the wrong medication. Therefore, the priority action is to collect data from the client.

Which statement describes a client in the stage of contemplation in the stages of change quizlet?

Which statement describes a client in the stage of contemplation in the stages of change? when sustained change is noticed over time, beginning 6 months after action has started and continuing indefinitely, the client has reached the maintenance stage.