Overview
This lecture focuses on NCLEX prioritization strategies, specifically identifying the "unexpected finding" in assessment questions to determine which patient requires immediate attention.
NCLEX Prioritization Strategy: Unexpected Findings
- Prioritization questions often present a diagnosis and four assessment findings, asking which is most concerning.
- Three findings are typically expected for the diagnosis; one is unexpected and requires immediate intervention or reporting.
- The unexpected finding is always the highest priority for action or notification.
- Use this strategy during practice to build the habit for the exam.
Example Scenarios & Application
COPD Client on Oxygen
- Expected: Productive cough with white sputum, respiratory rate of 28, clubbing of fingernails.
- Unexpected: Drowsiness and difficulty to arouse (possible CO2 retention, high priority).
Heart Failure on Diuretics/ACE Inhibitors
- Expected: Dry cough (from ACE inhibitor), bilateral crackles, pitting edema.
- Unexpected: Potassium of 5.5 (hyperkalemia, urgent intervention required).
Pneumonia on IV Antibiotics
- Expected: Temp 100.8°F, shortness of breath with activity, elevated WBC.
- Unexpected: Rash on chest/arms (possible allergic reaction to antibiotics).
Liver Cirrhosis Managed Conservatively
- Expected: Jaundice and itching, abdominal distension (ascites), peripheral edema.
- Unexpected: Disorientation with asterixis (possible hepatic encephalopathy, complication).
Hyperthyroidism Admission
- Expected: Weight loss despite eating, tremors, heat intolerance, HR 100.
- Unexpected: Sore throat and fever (possible infection, report).
Schizophrenia on Antipsychotics
- Expected: Dry mouth, blurred vision, weight gain, restlessness/pacing.
- Unexpected: Muscle rigidity and high fever (neuroleptic malignant syndrome).
Peptic Ulcer on Proton Pump Inhibitors (PPI)
- Expected: Black tarry stools, occasional nausea, epigastric pain relieved by antacids.
- Unexpected: Positive for Helicobacter pylori (requires antibiotics, not just PPIs).
Bipolar Mania on Mood Stabilizer
- Expected: Sleeping little but energized, rapid speech, grandiose thoughts.
- Unexpected: Giving away personal belongings (possible suicidal ideation).
Major Depressive Disorder on Antidepressants
- Expected: Decreased appetite, constipation, occasional headaches.
- Unexpected: Improved energy but still withdrawn (risk of suicide increases as energy improves before mood).
Key Terms & Definitions
- Unexpected Finding — A clinical sign or symptom not typical of the diagnosis or treatment; signals need for immediate attention.
- NCLEX — National Council Licensure Examination for nurses.
- Asterixis — Flapping hand tremor, sign of hepatic encephalopathy.
- Neuroleptic Malignant Syndrome — Life-threatening reaction to antipsychotic drugs, includes fever and muscle rigidity.
Action Items / Next Steps
- Practice applying the "unexpected finding" strategy when answering NCLEX-style questions.
- Memorize classic expected findings for common diagnoses and treatments.
- Review side effects and complications of key medications and conditions.