A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A.    Wheezes - Latex Allergy. Wheezing is often associated with allergic reactions, including latex allergy. Latex allergy can cause airway constriction and result in wheezing.

B.    Tachycardia - All Thr ee Conditions (Malignant Hyperthermia, Latex Allergy, Hypovolemic Shock). Tachycardia can be a common response to stress or physiological changes. In malignant hyperthermia, tachycardia can occur due to the hypermetabolic state. Latex allergy can cause an anaphylactic reaction leading to tachycardia. In hypovolemic shock, the heart rate increases to compensate for decreased blood volume.

C.    Urticaria - Latex Allergy. Urticaria (hives) is a classic sign of an allergic reaction, including latex allergy.
 
D.    Hypercapnia - Malignant Hyperthermia. Hypercapnia (elevated levels of carbon dioxide in the blood) can be a sign of malignant hyperthermia due to increased muscle metabolism and metabolic acidosis.

E.    Muscle Rigidity - Malignant Hyperthermia. Muscle rigidity is a hallmark sign of malignant hyperthermia, a rare but potentially life-threatening reaction to certain medications used during anesthesia.

The correct answer is Choice A.

Choice A rationale: “What are the voices telling you?” This is the priority response because it directly addresses the client’s immediate concern. The nurse is acknowledging the client’s experience and seeking to understand more about it. This can help the nurse assess the potential for harm to the client or others, as the voices may be instructing the client to engage in dangerous behaviors.

Choice B rationale: “Have you taken your medication today?” While medication adherence is important in managing schizophrenia, this response does not address the client’s immediate concern about hearing voices. It may also come across as dismissive of the client’s experience.

Choice C rationale: “I realize the voices are real to you, but I don’t hear anything.” This response validates the client’s experience, but it does not gather further information about what the voices are saying, which is crucial for assessing safety.

Choice D rationale: “How long have you been hearing the voices?” While this question is relevant for understanding the client’s history and the progression of their illness, it is not the priority response. The immediate concern should be what the voices are saying to assess for potential harm.