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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Husky voice and hoarseness are not typically associated with Cushing's syndrome but may be related to other conditions affecting the throat or vocal cords.
B. Central type obesity, with thin extremities, is a classic manifestation of Cushing's syndrome due to excess cortisol, which promotes fat accumulation in the trunk and face while causing muscle wasting in the extremities.
C. Warm, soft, moist, salmon-colored skin is not typically associated with Cushing's syndrome and may indicate other dermatological conditions.
D. Visible swelling of the neck with no pain is not a characteristic finding of Cushing's syndrome and may indicate other underlying issues such as goiter or lymphadenopathy.
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.
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