A diabetic client states he feels depressed, is complaining of chest pain, and has an open wound. Which of these complaints would require an immediate focused assessment?
Open wound
Depression
Chest pain
Diabetes
The Correct Answer is C
Choice A reason: An open wound is a concern for a diabetic client, as it can increase the risk of infection and delay the healing process. However, it does not require an immediate focused assessment, unless it is bleeding profusely, infected, or showing signs of tissue damage.
Choice B reason: Depression is a common complication of diabetes, as it can affect the client's mood, self-care, and adherence to treatment. However, it does not require an immediate focused assessment, unless the client is suicidal, psychotic, or unable to function.
Choice C reason: Chest pain is a symptom that can indicate a life-threatening condition, such as a heart attack, pulmonary embolism, or aortic dissection. It requires an immediate focused assessment, as it can compromise the client's cardiac and respiratory function and lead to death.
Choice D reason: Diabetes is a chronic condition that affects the client's blood glucose levels and can cause various complications, such as neuropathy, nephropathy, and retinopathy. However, it does not require an immediate focused assessment, unless the client is experiencing a hyperglycemic or hypoglycemic crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because stopping the KCl infusion is the first and most urgent action that the nurse should take. A high level of potassium in the blood, or hyperkalemia, can cause life-threatening cardiac arrhythmias and muscle weakness. The nurse should stop the source of excess potassium, which is the KCl infusion, and monitor the client's vital signs, electrocardiogram, and symptoms.
Choice B reason: This is not the correct answer because administering oral KCl is not the first or appropriate action that the nurse should take. Oral KCl would increase the potassium level in the blood, which is already too high. The nurse should avoid giving any potassium supplements or foods that are high in potassium, such as bananas, oranges, and potatoes.
Choice C reason: This is not the correct answer because encouraging fluids for dilution is not the first or effective action that the nurse should take. Fluids alone would not lower the potassium level in the blood, but rather dilute the concentration of other electrolytes, such as sodium and calcium. The nurse should administer fluids only as prescribed by the physician, and in conjunction with other treatments, such as diuretics, insulin, or sodium bicarbonate.
Choice D reason: This is not the correct answer because calling the pharmacy is not the first or priority action that the nurse should take. Calling the pharmacy may be necessary to obtain the medications that can lower the potassium level in the blood, such as diuretics, insulin, or sodium bicarbonate. However, the nurse should first stop the KCl infusion and notify the physician, who will order the appropriate medications and dosages.
Correct Answer is C
Explanation
Choice A reason: Encouraging the patient to wait for 24 hours before applying new knowledge is not an effective strategy to promote learning. It may cause the patient to forget or lose interest in the information. The RN should encourage the patient to apply new knowledge as soon as possible to reinforce learning and improve retention.
Choice B reason: Organizing the content from complex to simple is not an effective strategy to promote learning. It may confuse or overwhelm the patient with too much information at once. The RN should organize the content from simple to complex, starting with the most essential and relevant information and building on it gradually.
Choice C reason: Repeating the key concepts is an effective strategy to promote learning. It helps the patient to remember and recall the important information and clarify any misunderstandings. The RN should repeat the key concepts at the beginning, during, and at the end of the lesson.
Choice D reason: Asking the patient to hold questions until after the lesson is completed is not an effective strategy to promote learning. It may discourage the patient from asking questions or expressing concerns that may affect their learning. The RN should encourage the patient to ask questions at any time and provide feedback and answers.
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