A nurse is preparing to care for a group of clients after receiving change-of-shift report. From which of the following clients should the nurse collect data first?

A client who has benign prostate hyperplasia (BPH) and reports dysuria

A client who has ulcerative colitis and reports diarrhea

A client who has emphysema and reports dyspnea

A client who has esophageal cancer and reports painful swallowing

Answer and Explanation

The Correct Answer is C

Choice A reason: A client who has BPH and reports dysuria is not the highest priority, because dysuria is a common symptom of BPH and does not indicate an acute complication. The nurse should monitor the client's urinary output and provide comfort measures.

Choice B reason: A client who has ulcerative colitis and reports diarrhea is not the highest priority, because diarrhea is a chronic symptom of ulcerative colitis and does not indicate an acute complication. The nurse should assess the client's hydration status and electrolyte levels and administer medications as prescribed.

Choice C reason: A client who has emphysema and reports dyspnea is the highest priority, because dyspnea is a sign of respiratory distress and can indicate an acute exacerbation of emphysema. The nurse should assess the client's oxygen saturation and respiratory rate and administer oxygen therapy as prescribed.

Choice D reason: A client who has esophageal cancer and reports painful swallowing is not the highest priority, because painful swallowing is a common symptom of esophageal cancer and does not indicate an acute complication. The nurse should provide the client with soft or liquid foods and administer analgesics as prescribed.

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Correct Answer is C

Explanation

Choice A reason: This is an incorrect action, because instructing the client to blink several times after instillation of the medication can cause the medication to drain out of the eye and reduce its effectiveness.

Choice B reason: This is a correct action, but not the best one. Asking the client to look straight ahead during instillation of the medication can help the nurse to aim the drop accurately and avoid touching the eye with the dropper.

Choice C reason: This is the best action, because applying pressure to the bridge of the nose after instillation of the medication can prevent the medication from entering the systemic circulation and causing adverse effects, such as bradycardia, hypotension, or bronchospasm.

Choice D reason: This is an incorrect action, because placing each drop of the medication directly on to the client's cornea can cause irritation, injury, or infection to the eye. The medication should be placed in the lower conjunctival sac of the eye.

A. Each client is different. We cannot predict what will happen. B. I can see that you are worried, but it's too soon to predict what will happen. C. Acute episodes are usually followed by remissions, which can last varying lengths of time. D. It's too early to think about the future. Let's focus on the present and take one day at a time.

Correct Answer is C

Explanation

Choice A reason: This is a vague and unhelpful response, because it does not provide any information or reassurance to the client who has a new diagnosis of MS. The nurse should explain the general course of MS and the possible variations among clients.

Choice B reason: This is a sympathetic but incomplete response, because it does not address the client's question or provide any information about the course of MS. The nurse should acknowledge the client's feelings and provide factual and realistic information.

Choice C reason: This is the best response, because it provides accurate and relevant information about the course of MS, which is a chronic and progressive disease that affects the central nervous system. MS can cause acute episodes of neurological symptoms, such as vision loss, numbness, weakness, or fatigue, which are followed by periods of remission, when the symptoms improve or disappear. The length and frequency of the episodes and remissions can vary among clients.

Choice D reason: This is a dismissive and unrealistic response, because it does not answer the client's question or respect the client's right to know about the course of MS. The nurse should not avoid the client's concerns or minimize the impact of the diagnosis. The nurse should help the client cope with the uncertainty and plan for the future.

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A nurse is preparing to care for a group of clients after receiving change-of-shift report. From which of the following clients should the nurse collect data first?

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