The nurse observes the client as he walks into the clinic. She notices a slight tremor of the hands, slowness of movements, and a mask-like facial expression, with postural instability. Which of the following in the client's history are consistent with these observations?

Choice A Reason: The client needs total nursing care is the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which is a tool that measures the level of consciousness based on eye opening, verbal response, and motor response. A score of 6 indicates severe brain injury and coma, meaning that the client is unresponsive and dependent on others for all activities of daily living.

Choice B Reason: Indicates stable neurologic status is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. A stable neurologic status means that there are no changes in the level of consciousness, vital signs, or neurological signs.

Choice C Reason: The client has a decline in level of consciousness but is able to protect his airway is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. A decline in level of consciousness means that the client is less alert and responsive than normal, but still able to respond to stimuli and maintain airway patency.

Choice D Reason: The client is alert and oriented is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. Alert and oriented means that the client is fully awake and aware of person, place, time, and situation.

Choice A reason: This is the correct answer because airway obstruction is the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Airway obstruction can occur due to edema, inflammation, or inhalation injury of
the upper airway structures. It can compromise oxygenation and ventilation, and lead to respiratory failure or cardiac arrest. The nurse should assess for signs of airway obstruction, such as stridor, hoarseness, dyspnea, or cyanosis, and provide oxygen therapy, humidification, or intubation as needed.

Choice B reason: This is incorrect because fluid imbalance is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Fluid imbalance can occur due to fluid loss from damaged skin and capillaries, as well as increased capillary permeability and fluid shifts. It can cause dehydration, hypovolemia, shock, or electrolyte imbalances. The nurse should monitor fluid status, vital signs, urine output, and laboratory values, and provide fluid resuscitation as prescribed, but only after ensuring airway patency.

Choice C reason: This is incorrect because paralytic ileus is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Paralytic ileus is a condition where there is decreased or absent bowel motility due to nerve damage or decreased blood flow to
the gastrointestinal tract. It can cause abdominal distension, nausea, vomiting, or constipation. The nurse should assess bowel sounds, abdominal girth, and stool characteristics, and provide nasogastric suction or laxatives as prescribed, but only after ensuring airway patency and fluid balance.

Choice D reason: This is incorrect because infection is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Infection can occur due to loss of skin barrier, exposure to microorganisms, or impaired immune system. It can cause fever, increased pain, purulent drainage, or sepsis. The nurse should assess for signs of infection, obtain wound cultures, and administer antibiotics as prescribed, but only after ensuring airway patency, fluid balance, and pain control.