A nurse in a community health clinic is assessing a client brought by their parents. Which of the following would be the highest priority nursing diagnosis?

Risk for caregiver role strain

Risk for delayed development

Sleep deprivation

Altered urinary elimination

Answer and Explanation

The Correct Answer is B

Choice A reason: Caregiver role strain addresses the burden on parents or guardians. While important, it is not the highest priority compared to the client’s direct health needs. Developmental issues in a child take precedence, as they can have long-term impacts on physical, cognitive, and social growth, requiring immediate intervention.

Choice B reason: Risk for delayed development is critical in pediatric clients, as it affects cognitive, physical, and emotional growth. Early identification and intervention can mitigate long-term consequences, such as learning disabilities or social deficits. This diagnosis takes priority, as it directly impacts the child’s health and future functioning, requiring urgent attention.

Choice C reason: Sleep deprivation can affect health and development but is less urgent than developmental delays, which have broader, long-term consequences. Sleep issues may contribute to developmental problems but are typically secondary. Addressing underlying causes, like developmental risks, often resolves related symptoms like poor sleep more effectively.

Choice D reason: Altered urinary elimination, such as incontinence, may indicate a medical issue but is generally less critical than developmental delays in a pediatric client. It may be a symptom of developmental issues but does not take precedence over addressing potential delays that impact overall growth and function.

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Correct Answer is A

Explanation

Choice A reason: Hypomagnesemia, low magnesium (normal 1.7–2.2 mg/dL), is indicated by the 0.8 mEq/L value. Magnesium is vital for muscle, nerve, and cardiac function. Low levels can cause tremors, seizures, and arrhythmias. The other values (sodium, chloride, potassium) are within normal ranges, making hypomagnesemia the primary imbalance.

Choice B reason: Hyponatremia, low sodium (normal 135–145 mEq/L), is not indicated, as the sodium level is 140 mEq/L, within normal limits. Hyponatremia can cause neurological symptoms like confusion, but the lab values do not support this diagnosis, and magnesium imbalance is the clear abnormality.

Choice C reason: Hyperchloremia, high chloride (normal 98–106 mEq/L), is not present, as the chloride level is 107 mEq/L, just above normal and not clinically significant. Elevated chloride may occur in dehydration or renal issues, but the primary concern here is the significantly low magnesium level.

Choice D reason: Hypokalemia, low potassium (normal 3.5–5.0 mEq/L), is not indicated, as the potassium level is 3.6 mEq/L, within normal range. Hypokalemia causes muscle weakness and arrhythmias, but the lab values point to hypomagnesemia as the primary electrolyte imbalance in this case.

A. Have you been having swelling in your legs? B. Have you been experiencing difficulty breathing? C. Have you been experiencing chest pain? D. Have you been experiencing heart palpitations?

Correct Answer is B

Explanation

Choice A reason: Leg swelling (edema) is a symptom of heart failure due to fluid retention from poor cardiac output. However, it is less urgent than breathing difficulties, which indicate pulmonary edema, a life-threatening complication. Assessing breathing takes priority, as it directly affects oxygenation, a critical physiological need.

Choice B reason: Difficulty breathing (dyspnea) is a hallmark of heart failure, often due to pulmonary edema from fluid backup in the lungs. This compromises oxygenation, making it a life-threatening symptom requiring immediate assessment. The ABCD-E framework prioritizes breathing, making this the most critical question to evaluate heart failure severity.

Choice C reason: Chest pain may indicate angina or myocardial infarction, which can contribute to heart failure. However, it is less specific to heart failure than dyspnea, which directly signals pulmonary congestion. Breathing difficulties pose a more immediate threat, as they affect oxygenation, a priority in acute heart failure assessment.

Choice D reason: Heart palpitations may occur in heart failure due to arrhythmias but are less specific and urgent than dyspnea. Palpitations may indicate stress or other conditions, but breathing difficulties directly reflect pulmonary edema, a critical complication requiring immediate attention to ensure adequate oxygenation and prevent respiratory failure.

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A nurse in a community health clinic is assessing a client brought by their parents. Which of the following would be the highest priority nursing diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

As the nurse assesses a client’s laboratory values, the following are noted: Sodium 140 mEq/L, Magnesium 0.8 mEq/L, Chloride 107 mEq/L, Potassium 3.6 mEq/L. What electrolyte imbalance is indicated?

Correct Answer is A

Explanation

The nurse is assessing a client and asks which of the following questions to evaluate potential heart failure symptoms?

Correct Answer is B

Explanation

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