A nurse is prioritizing care for four clients following change-of-shift report. Which of the following clients should the nurse attend to first?

A client who has Alzheimer's disease and requires assistance to the bathroom

A client who has diverticulitis and a temperature of 38.3° C (100.9° F)

A client who has a prescription for a sputum specimen to be obtained before breakfast

A client who sustained a head injury 2 days ago and has a decreased level of consciousness

Answer and Explanation

The Correct Answer is D

A. A client who has Alzheimer's disease and requires assistance to the bathroom: This is important but less urgent compared to the risk of worsening condition in a client with a decreased level of consciousness.
B. A client who has diverticulitis and a temperature of 38.3° C (100.9° F): This is a concern, but it is not as immediately critical as a decreased level of consciousness, which may indicate a more severe underlying issue.
C. A client who has a prescription for a sputum specimen to be obtained before breakfast: While important for diagnostic purposes, this is less urgent compared to a decreased level of consciousness.
D. A client who sustained a head injury 2 days ago and has a decreased level of consciousness: This is correct because a decreased level of consciousness in a client with a recent head injury could indicate a serious complication, such as increased intracranial pressure or worsening of their condition, requiring immediate assessment and intervention.

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Correct Answer is C

Explanation

A. Monthly vitamin B12 injections: This is incorrect as vitamin B12 injections are not associated with osteoporosis. They are often used to address vitamin B12 deficiency, which is not a direct risk factor for osteoporosis.
B. History of kidney stones: This is incorrect because while kidney stones can be associated with calcium metabolism issues, they are not a primary risk factor for osteoporosis.
C. Long-term use of prednisone: This is correct as long-term use of corticosteroids like prednisone can lead to decreased bone density and increased risk of osteoporosis due to their impact on bone metabolism.
D. Congenital heart murmur: This is incorrect as a congenital heart murmur is not related to the development of osteoporosis.

A. Changed mental status B. WBC count 9,000/mm³ (5000 to 10,000/mm³) C. Diminished reflexes D. Temperature 37.3° C (99.1° F)

Correct Answer is A

Explanation

A. Changed mental status: This is a common indicator of a bladder infection in older adults, who may present with confusion or altered mental status instead of classic symptoms like dysuria or frequency.
B. WBC count 9,000/mm³ (5000 to 10,000/mm³): This WBC count is within the normal range and does not specifically indicate a bladder infection.
C. Diminished reflexes: This is not a typical indicator of a bladder infection and may suggest other neurological issues.
D. Temperature 37.3° C (99.1° F): This temperature is within the normal range and does not suggest an infection unless elevated or accompanied by other symptoms.

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A nurse is prioritizing care for four clients following change-of-shift report. Which of the following clients should the nurse attend to first?

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