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 D
Explanation
Choice A reason: Saying “That must be terrible” and suggesting a pinched nerve is dismissive and assumes a cause without assessment. Exploring the pain’s impact gathers critical data, so this is incorrect for an appropriate response.
Choice B reason: Asking about family reactions shifts focus from the patient’s experience and is less relevant initially. Assessing how the pain affects daily activities provides functional insight, so this is not the best response for pain assessment.
Choice C reason: Sharing personal experience can seem empathetic, but it this risks bias and doesn’t assess the patient’s pain. Asking about daily activity impact is more patient-centered, so this is incorrect for professional response.
Choice D reason: Asking how pain affects daily activities encourages the patient to describe the pain’s severity and impact, aiding assessment and planning. This open-ended, patient-focused response is therapeutic, making it the correct choice for the nurse’s reply.
Correct Answer is B
Explanation
Choice A reason: Offering a finger may elicit sucking, not rooting, which involves head-turning toward a stimulus. Stroking the cheek triggers the rooting reflex, so this is incorrect for testing the specific reflex.
Choice B reason: Stroking the infant’s cheek near the mouth elicits the rooting reflex, causing the newborn to turn toward the stimulus, seeking to nurse. This is the correct technique for testing this reflex.
Choice C reason: Jarring the crib tests the Moro reflex, not rooting, which is unrelated to startle responses. Cheek stroking is specific to rooting, so this incorrect for the reflex being assessed.
Choice D reason: Stroking the foot edge tests the Babinski reflex, not rooting, which involves oral seeking. The cheek is the correct area to stimulate, so this is incorrect for the rooting reflex.
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