A nurse is planning care of a group of clients at the beginning of their shift. Which of the following clients should the nurse care for first?

A client who has a burn requiring a sterile dressing change

A client who had an appendectomy 6 hr ago and has diminished bowel sounds

A client who received a chemotherapy treatment and reports nausea

A client who has hypothyroidism and is stuporous

Answer and Explanation

The Correct Answer is D

A. A client who has a burn requiring a sterile dressing change: While burn care is important to prevent infection and promote healing, a dressing change is not immediately life-threatening. This task can be safely addressed after assessing clients with higher-priority acute risks.

B. A client who had an appendectomy 6 hr ago and has diminished bowel sounds: Diminished bowel sounds are common in the immediate postoperative period and do not usually indicate an emergent problem. This client requires ongoing monitoring, but there is no acute threat to life at this time.

C. A client who received a chemotherapy treatment and reports nausea: Nausea following chemotherapy is uncomfortable and should be managed promptly, but it is not immediately life-threatening. Interventions such as antiemetics can be provided after more urgent needs are addressed.

D. A client who has hypothyroidism and is stuporous: Stupor in a client with hypothyroidism may indicate myxedema or severe hypothyroid crisis, which can be life-threatening due to risk of respiratory depression, cardiovascular compromise, or altered mental status. This client requires immediate assessment and intervention, making them the highest priority.

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Correct Answer is B

Explanation

A. Monitor the client for hypothermia: Hypothermia is not a typical adverse effect of haloperidol. The medication more commonly causes extrapyramidal symptoms and neuroleptic malignant syndrome, which may include hyperthermia rather than hypothermia.

B. Screen the client for tardive dyskinesia: Tardive dyskinesia is a serious, potentially irreversible extrapyramidal side effect associated with long-term use of antipsychotics such as haloperidol. Routine screening using tools like the Abnormal Involuntary Movement Scale (AIMS) is essential to detect early signs and adjust therapy as needed.

C. Check the client's weekly potassium level: Haloperidol does not typically affect potassium levels. Routine electrolyte monitoring is not indicated unless the client has other conditions or is taking medications that affect potassium.

D. Schedule the client for a 24-hr urine collection: A 24-hour urine collection is unrelated to haloperidol therapy. This test is used to assess kidney function or specific metabolic conditions and is not part of routine care for clients taking antipsychotics.

A. "I don't hear the voices. Concentrate on my voice instead." B. "They cannot hurt you. Don't be afraid of what they say." C. "Let's go to a quiet room where the voices won't follow." D. "The voices are not real, and you need to get to group."

Correct Answer is A

Explanation

A. "I don't hear the voices. Concentrate on my voice instead.": This response validates the client’s experience without reinforcing the hallucination and redirects attention to reality. It helps the client focus on the present environment and encourages engagement in reality-based interactions, which is a therapeutic approach for managing auditory hallucinations.

B. "They cannot hurt you. Don't be afraid of what they say.": While intended to reassure, this response may be dismissive of the client’s experience and can increase anxiety or mistrust. It does not provide a practical strategy for coping with the hallucinations.

C. "Let's go to a quiet room where the voices won't follow.": Hallucinations are internally generated and are not affected by the external environment. Moving to a quiet room may not decrease the hallucinations and can inadvertently reinforce the belief in their reality.

D. "The voices are not real, and you need to get to group.": Telling the client the voices are not real can invalidate their experience and reduce therapeutic rapport. Forcing participation in activities without addressing the hallucinations can increase stress and noncompliance.

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A nurse is planning care of a group of clients at the beginning of their shift. Which of the following clients should the nurse care for first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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