A client with a renal calculus reports severe right flank pain, nausea, and vomiting.
Which nursing problem has the highest priority?

Acute pain related to renal calculus.

Nutritional deficit related to nausea.

Impaired renal function related to pain.

Risk for aspiration related to vomiting.

Answer and Explanation

The Correct Answer is D

A. Acute pain related to renal calculus is important and needs to be addressed, but managing potential life-threatening conditions, like aspiration, takes precedence.

B. Nutritional deficit related to nausea is also a concern but is not as urgent as preventing aspiration.

C. Impaired renal function related to pain could be important in the long term, but it does not pose an immediate risk like aspiration does. Therefore, it is not the highest priority.

D. Risk for aspiration related to vomiting is the highest priority because it addresses the immediate potential for airway compromise, which can be life-threatening if the client aspirates vomitus. Ensuring the airway is protected and that aspiration does not occur is critical.

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Correct Answer is D

Explanation

A. Increasing anxiety may require intervention, but it does not pose an immediate threat to the client's health compared to other options.

B. Inappropriate laughter could indicate emotional lability, a common symptom in ALS, but it does not typically require immediate intervention unless it's accompanied by other concerning symptoms.

C. Asymmetrical weakness is common in ALS but may not necessarily warrant immediate intervention unless it is significantly affecting the client's ability to perform essential functions.

D. Weakened cough effort is a critical finding in a client with ALS, as it can lead to ineffective airway clearance and increase the risk of aspiration pneumonia. Immediate intervention, such as suctioning or respiratory support, may be necessary to maintain airway patency and prevent complications.

A. Palpitations and shortness of breath. B. Bradycardia and constipation. C. Muscle cramping and dry, flushed skin. D. Lethargy and lack of appetite.

Correct Answer is A

Explanation

A. Palpitations and shortness of breath are symptoms of thyrotoxicosis, indicating excessive thyroid hormone levels, which could result from an overdose of levothyroxine sodium.

B. Bradycardia and constipation are more indicative of hypothyroidism, which would suggest the need for an increase in levothyroxine dosage rather than a decrease.

C. Muscle cramping and dry, flushed skin are symptoms of hypothyroidism, which would suggest inadequate thyroid hormone replacement rather than excess.

D. Lethargy and lack of appetite are also symptoms of hypothyroidism, not hyperthyroidism, which would not typically result from an overdose of levothyroxine.

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A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

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A client with a renal calculus reports severe right flank pain, nausea, and vomiting.
Which nursing problem has the highest priority?