A nurse is assessing a client whose therapy has included bed rest for several weeks.
Which of the following findings should the nurse identify as the priority?
Loss of appetite
Left lower extremity tenderness
Increased heart rate during physical activity
Musculoskeletal weakness
The Correct Answer is B
A. While decreased appetite may be concerning, it is not typically considered a priority over potential complications related to immobility.
B. Left lower extremity tenderness could indicate deep vein thrombosis (DVT), a serious complication of prolonged bed rest that requires immediate attention to prevent pulmonary embolism.
C. Increased heart rate during physical activity may be expected after a period of bed rest and can be addressed with gradual reconditioning.
D. Musculoskeletal weakness is a common consequence of immobility and would be addressed as part of the client's rehabilitation but is not an immediate priority compared to potential complications like DVT.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtaining the client's type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery.
B. This is important but should only be done after obtaining the client’s type and cross-match.
C. This should be done after obtaining the client’s type and cross-match.
D. While an incident report may be necessary, the immediate priority is to address the oversight and ensure patient safety.
Correct Answer is A
Explanation
A. Denial is the first stage of grief, in which the person refuses to accept the reality of their situation and tries to maintain a sense of normalcy. The client who says they are looking forward to seeing their grandchildren grow up is denying the fact that they have a terminal illness and that they may not live long enough to witness that.
B. Bargaining involves making deals with self and God to help feel better, for instance, in this case the client will be expressing the will to do anything to prolong his life.
C. Acceptance involves coming to terms with the reality of the situation and preparing for death. The client's statement does not indicate full acceptance.
D. Anger involves feelings of resentment or frustration. The client's statement does not express anger towards their situation.
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