An adolescent has just returned from surgery after spinal fusion surgery. Which assessment finding would take priority at this time?
1. Sleeps when not bothered but arouses easily with stimuli
2. Impaired color, sensitivity, and movement to lower extremities
3. Nausea
4. Pain
2
Rationale 1: This is a normal response postanesthesia.
Rationale 2: When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement to lower extremities.
Rationale 3: Nausea in the postoperative period is not uncommon, but it is not the priority at this time.
Rationale 4: Pain is a common finding in the postoperative period and should be addressed, but impaired color, sensitivity, and movement of the lower extremities is the priority at this time.
Global Rationale:
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