A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first?
a. Client who has been diagnosed with meningitis with a fever of 101 ° F (38.3 ° C)
b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix)
c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate
d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed
ANS: C
The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed. The client with meningitis has expected manifestations. The client waiting for discharge teaching is a lower priority. The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t-PA, or the nurse could delegate checking on this client to another nurse.
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