A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
Breathing, pain, and sleep.
Breathing, sleep, and pain.
Sleep, breathing, and pain.
Sleep, pain, and breathing.
The Correct Answer is A
Choice A reason: Breathing difficulty is the highest priority, as it affects oxygenation, a life-threatening issue. Pain is next, impacting comfort and recovery, followed by sleep, which supports healing. This follows the ABC (Airway, Breathing, Circulation) prioritization, making it the correct order for addressing the patient’s issues.
Choice B reason: Prioritizing sleep over pain after breathing is incorrect; pain is more urgent, as it distresses and affects recovery, while sleep is secondary. Breathing remains first, but pain precedes sleep, so this is incorrect for prioritization.
Choice C reason: Sleep as the first priority ignores breathing, a critical life-threatening issue. Breathing and pain are more urgent, with sleep supporting long-term recovery, so this is incorrect for acute care prioritization principles.
Choice D reason: Placing sleep first and breathing last disregards life-threatening breathing issues. Breathing, then pain, then sleep align with ABC priorities, ensuring patient patient safety, so this is incorrect for the nurse’s approach.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A complete physical exam is comprehensive but not specific to initial nutritional screening. Height and weight history provide BMI, a quick nutritional indicator, so this is not the first assessment.
Choice B reason: Height and weight history are critical for initial nutritional screening, enabling BMI calculation to assess undernutrition or obesity. This is a standard, quick method, making it the correct first step.
Choice C reason: Calorie counting is detailed and time-consuming, unsuitable for initial screening. Height and weight offer a rapid baseline for nutritional status, so this is incorrect for the first step.
Choice D reason: Leg circumference may assess muscle mass but is not standard for initial nutritional screening. Height and weight are primary for BMI, so this is incorrect for the initial assessment.
Correct Answer is D
Explanation
Choice A reason: Superficial tenderness is assessed with light palpation, which evaluates surface sensitivity. Deep palpation probes deeper structures, like organs, and is not primarily for detecting superficial pain, making this an incorrect rationale.
Choice B reason: Bowel motility is assessed via auscultation, which detects bowel sounds, not palpation. Deep palpation evaluates organ size or masses, not dynamic motility, making this an incorrect purpose for the technique.
Choice C reason: The overall impression of skin and superficial musculature is gained through inspection and light palpation. Deep palpation targets deeper structures like organs, not surface characteristics, making this an incorrect rationale.
Choice D reason: Deep palpation is used to assess for enlarged organs, such as hepatomegaly or splenomegaly, by probing deeper abdominal structures. This allows detection of abnormal masses or organ sizes, making this the correct rationale.
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