A nurse is caring for four clients. Which of the following clients should the nurse assess first?
A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness
A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL
A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10
A client who is 3 days postoperative following abdominal surgery and is ready for discharge
The Correct Answer is A
a. The client with Alzheimer's disease and bacterial pneumonia experiencing newly onset restlessness may indicate a change in their condition, such as worsening infection or delirium, which requires immediate assessment and intervention to address their underlying medical needs.
b. While hyperglycemia in a newly admitted client with diabetes mellitus is concerning, it does not typically require immediate assessment unless accompanied by signs of diabetic ketoacidosis or other acute complications.
c. Although the client postoperative from hip fracture reduction reporting a pain level of 7 requires attention, it is not as urgent as assessing the client with newly onset restlessness, which may indicate a more acute issue.
d. The client who is 3 days postoperative and ready for discharge does not require immediate assessment compared to the client with newly onset restlessness, whose condition may be deteriorating.
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Correct Answer is D
Explanation
a. While a client with type 1 diabetes using an insulin pump may require interdisciplinary collaboration for optimal management, this scenario does not suggest an immediate need for an interdisciplinary conference.
b. A client receiving heparin with an aPTT of 34 seconds may require adjustment of the heparin dosage, but this situation does not necessitate an interdisciplinary conference.
c. A client with orthostatic hypotension receiving IV fluids may require close monitoring and collaboration among healthcare providers, but this situation does not suggest an immediate need for an interdisciplinary conference.
d. A client at risk for pressure ulcers with an albumin level of 4.2 g/dl may require an interdisciplinary conference to address nutrition, wound care, and preventive measures to reduce the risk of pressure ulcer development.
Correct Answer is C
Explanation
. Inform the client that she cannot leave without a discharge prescription from the provider
Rationale:
a. Offering a sedative may not address the client's concerns and is not an appropriate response to the situation.
b.Inform the client that she cannot leave without a discharge prescription from the provider. Clients have the right to leave against medical advice; informing them otherwise infringes on their rights.
C Have the client sign the Against Medical Advice form. This action respects the client's autonomy while ensuring documentation of her decision to leave against medical advice, which protects both the client and healthcare facility legally.
d. Assigning a security officer to the client's room may escalate the situation unnecessarily. The focus should be on communication and education.
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