What is the client’s immediate health problem?

Activity Instructions
Please review the initial clinical scenario (above) and complete the following questions:

Download the blank concept map PDF for this activity.
1. Recognize Cues: What data did you identify as relevant?
2. Analyze Cues:
a. \Which situation poses the greatest or most immediate risk to the client?
b. Why or why not?
3. Prioritize Hypotheses:
a. What is the client’s immediate health problem?
4. Generate Solutions:
a. What client attributes must you consider in planning for this client?
5. Take Actions:
a. Which interventions should be performed first?
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Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.
Case Study (1 of 2)
• A 73-year-old client is admitted to
PACU after having a
cholecystectomy. The client had
general anesthesia and has a
dressing to the right upper
quadrant of abdomen. Dry and
intact. The client is not arousable
and is unable to control the airway.
The client received 4 mg of
morphine at the end of the
procedure.
• Vital signs
• Temperature: 97.4° F (36.33° C)
• Blood pressure: 178/86
• Pulse: 76 irregular
• Respirations: 16
• Oxygen Saturation: 96% 3L/NC
• Blood glucose: 115 mg/dL
• The client has a history of diabetes
mellitus type 2, hypertension, and
atrial fibrillation. All conditions are
controlled by medication.
• Home medications
• Glipizide 10 mg BID
• Metoprolol 50 mg Daily
• Rivaroxaban (Xarelto) 15 mg daily
(stopped 3 days prior per preoperative
orders)
Activity Instructions
Review the unfolding clinical scenario information below and discuss.
Evaluate Outcomes –
• What client outcomes would indicate that your client’s condition has improved or
worsened?
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Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.
Case Study (2 of 2)
• The client is arousable and able to speak. Head of the bed elevated 30°.
The dressing to the right upper quadrant of abdomen remains dry and
intact.
• Vital signs
• Temperature: 97.4° F (36.33° C)
• Blood pressure: 184/88
• Pulse: 80 irregular
• Respirations: 14
• Oxygen Saturation: 98% 2L/NC
41
Copyright 2023 Assessment Technologies Institute, L.L.C. All rights reserved.
Self-Reflection Activity
• Complete the following questions and submit them to your instructor.

• How can you provide the best support for the client and family prior to surgery?
• It is important to consider a client level of health literacy when providing discharge
teaching. How would you, the nurse, approach a client differently based on levels of
health literacy?

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