A client arrives reporting redness, warmth, and swelling after stepping on a nail one week ago. What is the nurse's priority action?
A Cleanse the wound
B Identify when the client was immunized
C Dress the wound
D Request an X-Ray
The Correct Answer is D
Choice A Rationale: Cleansing the wound may be necessary, but the priority in this case is to assess for any retained foreign bodies, such as the nail, and potential structural damage, which can be done through an X-ray.
Choice B Rationale: The client's immunization history is not the priority when assessing and managing a wound like this.
Choice C Rationale: Dressing the wound may be necessary but should come after assessing for retained foreign bodies and potential structural damage.
Choice D Rationale: Requesting an X-ray is the priority action because it helps determine if the nail is still present and if there is any damage to deeper structures, such as bones or foreign body remnants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Rationale: Simple puzzles are appropriate activities for a client with severe Alzheimer's because they stimulate cognitive function and provide a sense of accomplishment.
Choice B Rationale: Board games are too complex and frustrating for a client with severe Alzheimer's, as they require memory, strategy, and social interaction.
Choice C Rationale: Dangling ribbons or a mobile are infantile and demeaning activities that do not respect the dignity and autonomy of the client.
Choice D Rationale: Drawing with crayons may be suitable for some clients with Alzheimer's, but it is not specific to the diagnosis and may not appeal to all clients.
Correct Answer is A
Explanation
Choice A Rationale: some medications that are used to calm down people with dementia can have serious side effects, especially for older adults. One of these side effects is an increased risk of experiencing a stroke, which can be life-threatening.
Choice B Rationale: Increased blood pressure can be a side effect of some medications used to calm patients with dementia, but it may not be the primary reason for not prescribing such medications. Furthermore, some medications can lower blood pressure, not increase it.
Choice C Rationale: Increased risk for infection is not typically a reason to avoid medications to calm dementia patients.
Choice D Rationale: is partially true because some medications can increase the risk for falls, but this is not the main reason why they are avoided.
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