A nurse has received a report on a group of clients. Which of the following clients should the nurse assess first?

A client who has type 2 diabetes mellitus with a blood glucose level of 120 mg/dL (normal range: 74-106 mg/dL).

A client who has diabetes insipidus with an intake of 1,500 mL and an output of 1,600 mL in 24 hours.

A client who has Graves' disease with a heart rate of 100/min and reports tremors.

A client who has had a left-sided stroke reports a severe headache and is manifesting confusion.

Answer and Explanation

The Correct Answer is D

Choice A reason:
While a blood glucose level of 120 mg/dL is slightly above the normal range, it is not typically considered an emergency for a client with type 2 diabetes mellitus. This client would require monitoring and potential adjustment of their diabetes management plan, but it does not necessitate immediate assessment.

Choice B reason:
For a client with diabetes insipidus, an intake of 1,500 mL and an output of 1,600 mL in 24 hours is within expected parameters, considering the condition's characteristic polyuria and polydipsia. This client would need ongoing monitoring to maintain fluid balance but is not the highest priority for immediate assessment.

Choice C reason:
A heart rate of 100/min and tremors in a client with Graves' disease could indicate that their condition is not well-controlled. However, these symptoms are not as acutely concerning as those of a stroke and would be addressed after more urgent needs are met.

Choice D reason:
A client who has had a left-sided stroke and reports a severe headache and confusion is exhibiting signs of a possible acute neurological change or complication, such as increased intracranial pressure or hemorrhage. This client requires immediate assessment and intervention due to the potential for rapid deterioration and life-threatening complications.

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Correct Answer is ["A","D","E"]

Explanation

Choice B reason:
Sleeping on a soft mattress is not recommended for preventing low back pain. A medium-firm mattress often provides better support for the spine. A soft mattress may allow the body to sink in too deeply, causing misalignment of the spine during sleep.

Choice C reason:
Applying heat for 10 minutes every hour is not a standard recommendation for preventing low back pain. While heat therapy can help relax muscles and relieve pain, it is typically advised to apply heat for longer periods, such as 15-20 minutes, and not as frequently as every hour.

Choice D reason:
Sleeping in a side-lying position with flexed knees can help maintain the natural curve of the spine and minimize back strain. This position can also reduce pressure on the back and is often recommended for those with low back pain.

Choice E reason:
Trying padded shoe insoles can help minimize back strain by providing additional support and cushioning for the feet, which can improve alignment and reduce the impact on the back during walking or standing.

A. "Use a natural membrane condom rather than a polyurethane condom." B. "Female condoms can help prevent transmission of sexually transmitted viruses." C. "You may use a condom more than once." D. "Use an oil-based lubricant when you use a condom."

Correct Answer is B

Explanation

Choice A reason:

The statement about using a natural membrane condom rather than a polyurethane condom is incorrect. Natural membrane condoms, such as those made from lambskin, have small pores that can allow viruses to pass through. Therefore, they are not recommended for the prevention of STIs. Polyurethane condoms, on the other hand, do not have these pores and are considered effective in preventing STIs, including HIV.

Choice B reason:

Female condoms, also known as internal condoms, are effective in preventing the transmission of sexually transmitted viruses, including HIV. They act as a barrier to prevent the exchange of bodily fluids during sexual activity, thereby reducing the risk of STI transmission. It's important to include this information in the teaching as it empowers individuals with an additional option for protection.

Choice C reason:

Condoms are designed for single use only. Using a condom more than once greatly increases the risk of condom failure, which can lead to the transmission of STIs or unintended pregnancy. It is crucial to emphasize the importance of using a new condom for each act of sexual intercourse.

Choice D reason:

Oil-based lubricants should not be used with latex condoms as they can weaken the material, leading to condom breakage. Instead, water-based or silicone-based lubricants are recommended as they do not damage the condom and can help prevent breakage.

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A nurse has received a report on a group of clients. Which of the following clients should the nurse assess first?

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