Patient Data

Exhibits

Click to highlight the assessment findings that require immediate follow up by the nurse.

Client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.

Rationale

A. Continuing with the tracheostomy care procedure while a code blue is ongoing for another client is not appropriate. A code blue takes precedence as it indicates a life-threatening emergency requiring immediate response.

B. Closing the room door is not a priority action during a code blue. The immediate focus should be on responding to the emergency and providing assistance as needed.

C. If additional help is needed to assist with the tracheostomy care procedure, calling for an assistant could be appropriate under normal circumstances. However, during a code blue, the primary responsibility is to respond to the emergency immediately.

D. A code blue indicates a cardiac or respiratory arrest, which requires immediate intervention. As a nurse, responding to the code blue involves providing assistance with cardiopulmonary resuscitation (CPR), fetching emergency equipment, and supporting the healthcare team in resuscitative efforts.

After listening to the client's symptoms, the nurse realizes that she likely has acute stress disorderrelated to traumatic stress

Acute Stress Disorder: This diagnosis fits because the client is experiencing significant distress and anxiety related to the traumatic event (her house collapsing during a hurricane). Acute stress disorder is characterized by intrusive thoughts, nightmares, flashbacks, and avoidance behaviors following exposure to a traumatic event. The client's symptoms of persistent thoughts about the event, difficulty sleeping due to these thoughts, and feeling unable to return to her previous emotional state ("funk") are indicative of acute stress disorder.

Traumatic Stress: This describes the source of the client's symptoms. The collapse of her house during a hurricane is a traumatic event that has triggered her acute stress disorder symptoms. Traumatic stress refers to the psychological and emotional response to a deeply distressing or disturbing event.