A nurse is caring for a client in the clinic
Complete the following sentence by using the list of options.
The nurse should first address the client's
The Correct Answer is {"dropdown-group-1":"C"}
- Chest pain: Crushing, retrosternal chest pain is highly suggestive of cardiac ischemia or acute coronary syndrome. It requires immediate evaluation due to the risk of myocardial infarction. The presence of fatigue and weakness adds to the urgency. Chest pain is always prioritized due to its life-threatening potential.
- Visual disturbance: Visual changes may indicate hypertension, hyperglycemia, or neurological issues. While concerning, they are typically not immediately life-threatening. These symptoms can be evaluated after cardiac causes are ruled out. They support further systemic investigation.
- Fatigue: Fatigue is a nonspecific symptom seen in many chronic conditions like diabetes, anemia, or heart failure. It does not signal an emergency on its own. It may be related to underlying cardiac issues but is not prioritized over chest pain.
- Increased urination: Polyuria often indicates uncontrolled blood glucose levels or diabetes. It should prompt further testing but does not require immediate intervention. It is a chronic symptom rather than an acute, life-threatening one.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Typical pneumonia: Streptococcus pneumoniae is the most common bacterial cause of typical pneumonia. It typically presents with sudden onset of fever, productive cough with purulent sputum, and pleuritic chest pain. Chest x-rays often show lobar consolidation, which is characteristic of this type.
B. Aspiration pneumonia: Aspiration pneumonia results from inhalation of oropharyngeal or gastric contents into the lower airways. It is commonly associated with altered consciousness, swallowing disorders, or vomiting, and is not primarily caused by Streptococcus pneumoniae.
C. Atypical pneumonia: Atypical pneumonia is usually caused by organisms like Mycoplasma pneumoniae, Chlamydophila pneumoniae, or Legionella species. It tends to have a gradual onset with dry cough, low-grade fever, and diffuse infiltrates on imaging, which is different from the presentation of Streptococcus pneumoniae infection.
D. Chemical pneumonitis: Chemical pneumonitis is an inflammatory response in the lungs due to inhalation of irritants such as gastric acid or toxic fumes. It is not caused by bacterial infection and therefore is unrelated to Streptococcus pneumoniae.
Correct Answer is A
Explanation
A. Pulmonary edema: Pulmonary edema occurs when fluid accumulates in the lungs, impairing gas exchange and leading to hypoxemia. This condition is a common cause of hypoxemic respiratory failure, and patients often present with symptoms such as dyspnea, crackles on auscultation, and hypoxemia. The nurse would expect this finding in a client experiencing hypoxemic respiratory failure.
B. Opioid toxicity: Opioid toxicity can cause respiratory depression, but it typically leads to hypoventilation, which results in hypercapnic respiratory failure (elevated carbon dioxide levels) rather than hypoxemic respiratory failure. Therefore, while opioid toxicity affects breathing, it is not directly associated with hypoxemic respiratory failure.
C. Myasthenia gravis: Myasthenia gravis is a neuromuscular disorder that leads to muscle weakness, including respiratory muscles. While it can cause respiratory failure in severe cases, it does not directly cause hypoxemic respiratory failure. Respiratory failure in myasthenia gravis is often due to insufficient ventilation rather than impaired oxygenation, so this is not the expected finding in hypoxemic respiratory failure.
D. Flail chest: Flail chest occurs due to multiple rib fractures that result in a segment of the chest wall moving paradoxically, impairing ventilation. While this condition can lead to respiratory failure, it typically causes hypercapnic rather than hypoxemic respiratory failure. Therefore, it is less likely to be the cause of hypoxemic respiratory failure in this scenario.
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