A nurse in a long-term care facility is caring for a client with dementia who is upset over not being able to find their spouse, who passed away years ago. Which of the following actions should the nurse take first?

Choice A reason: Homeostasis is the body’s ability to maintain stable internal conditions, including fluid and electrolyte balance. Imbalances, like hypokalemia or hypernatremia, disrupt cellular function, potentially causing arrhythmias or neurological issues. Restoring homeostasis is the priority, as it addresses the root cause, ensuring proper organ function and preventing complications.

Choice B reason: Preventing infection is important but not the priority in fluid and electrolyte imbalances. Infections may occur secondary to other conditions, but the primary concern is correcting imbalances that affect cellular and organ function. Homeostasis must be achieved first to stabilize the client’s physiological state before addressing infection risks.

Choice C reason: Promoting mobility is relevant for overall health but not the priority in fluid and electrolyte imbalances. Imbalances can cause muscle weakness or arrhythmias, but restoring electrolyte levels takes precedence to ensure safe mobility. Without homeostasis, mobility efforts may be unsafe or ineffective due to physiological instability.

Choice D reason: Enhancing nutrition supports overall recovery but is secondary to correcting fluid and electrolyte imbalances. Nutritional deficiencies may contribute to imbalances, but the immediate goal is restoring homeostasis to prevent acute complications like cardiac or neurological dysfunction. Nutrition can be addressed once the client is stabilized.

Choice A reason: A chest X-ray may show secondary signs like atelectasis in pulmonary embolism but is not specific for diagnosis. It primarily rules out other conditions like pneumonia. Pulmonary embolism requires visualization of a clot, which X-rays cannot provide, making them insufficient for confirming the diagnosis.

Choice B reason: An ECG may show tachycardia or right heart strain in pulmonary embolism but is not diagnostic. It detects cardiac changes secondary to the embolism, not the clot itself. Specific imaging, like CT angiography, is needed to visualize the pulmonary artery obstruction for confirmation.

Choice C reason: CT pulmonary angiography is the gold standard for diagnosing pulmonary embolism, as it directly visualizes thrombi in pulmonary arteries using contrast-enhanced imaging. It confirms the presence, location, and extent of the clot, enabling rapid diagnosis and treatment to prevent life-threatening complications like right heart failure.

Choice D reason: Arterial blood gas may show hypoxemia or respiratory alkalosis in pulmonary embolism due to impaired gas exchange but is not diagnostic. It reflects physiological changes, not the clot itself. Imaging, like CT angiography, is required to confirm the presence of a pulmonary artery obstruction.