A nurse is receiving change-of-shift report about the care of four clients. Which of the following clients should the nurse see first?
A client who has a blood pressure of 138/88 mm Hg
A client who reports a pain level of 4 on a scale of 0 to 10
A client who has a blood glucose level of 128 mg/dL (74 to 106 mg/dL)
A client who displays increased confusion over the past 4 hr
The Correct Answer is D
A. A client who has a blood pressure of 138/88 mm Hg: This blood pressure is only slightly elevated and does not indicate immediate instability. The client is not at acute risk of deterioration, so this finding does not require priority assessment over neurologic changes.
B. A client who reports a pain level of 4 on a scale of 0 to 10: Moderate pain needs attention but does not suggest life-threatening compromise. This level of pain allows time for assessment and intervention without posing immediate danger compared to acute cognitive changes.
C. A client who has a blood glucose level of 128 mg/dL (74 to 106 mg/dL): A glucose of 128 mg/dL is mildly elevated and not emergent. It does not place the client at risk for imminent complications and can be addressed after more urgent concerns.
D. A client who displays increased confusion over the past 4 hr: Sudden or worsening confusion can indicate acute neurologic issues such as hypoxia, infection, stroke, or metabolic imbalance. Changes in level of consciousness are high-priority findings due to the potential for rapid deterioration, making this client the first to assess.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The first image depicts a finger injury with partial nail and tissue trauma, which represents a localized hand wound but does not involve internal organs. This is not evisceration.
B. The second image shows abdominal organs protruding through a surgical incision, which is the defining feature of evisceration. Evisceration is a surgical emergency requiring immediate intervention to protect the exposed organs and prevent infection.
Correct Answer is A
Explanation
A. "I will limit meat portions to 3 ounces per meal.": Keeping meat portions small helps reduce intake of saturated fats, which contribute to elevated LDL levels and progression of atherosclerosis. A 3-ounce serving aligns with heart-healthy guidelines and encourages the client to prioritize lean protein sources.
B. "I will limit baked goods to those containing trans fats.": Trans fats significantly raise LDL and lower HDL, making them among the most harmful fats for cardiovascular health. Choosing baked goods with trans fats directly worsens atherosclerosis risk.
C. "I will increase my consumption of 2-percent milk.": Two-percent milk still contains notable saturated fat, which can elevate LDL and contribute to plaque formation. Clients with atherosclerosis are encouraged to switch to low-fat or fat-free dairy products to reduce saturated fat intake. Increasing 2% milk is not consistent with dietary recommendations.
D. "I will use palm oil in my cooking.": Palm oil is high in saturated fats that promote LDL elevation and endothelial damage, worsening atherosclerotic progression. Clients with cardiovascular disease are advised to replace saturated fats with healthier plant oils like olive or canola.
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