A nurse is receiving change-of-shift report on four clients.
Which of the following clients should the nurse plan to see first?

A client who has cirrhosis and severe pruritus.

A client who has a femur fracture and reports numbness of the toes.

A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge.

A client who had a renal biopsy 3 hr ago and has pink-tinged urine.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

The client with cirrhosis and severe pruritus is experiencing discomfort, but it is not an immediate life-threatening situation. The priority should be given to clients with conditions that pose an immediate risk to life.

Choice B rationale:

Numbness of the toes in a client with a femur fracture can indicate compromised circulation or nerve damage. This is a critical situation that requires immediate assessment and intervention to prevent complications like compartment syndrome or permanent nerve damage.

Choice C rationale:

A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge is likely stable. While they need monitoring, it is not an urgent priority compared to the client with a potential vascular or nerve issue.

Choice D rationale:

Pink-tinged urine after a renal biopsy could indicate some bleeding, but it is not as urgent as the situation of the client with a femur fracture and numbness of the toes.

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Correct Answer is D

Explanation

The correct answer is d. Hallucinations.

Choice A reason: Hypothermia is not typically associated with MDMA use. Instead, MDMA can cause hyperthermia due to its stimulant effects.

Choice B reason: Muscle weakness is not a common effect of MDMA. The drug is more likely to cause increased energy and endurance.

Choice C reason: Somnolence, or a strong desire for sleep, is unlikely with MDMA use as it is a stimulant and tends to increase alertness.

Choice D reason: Hallucinations are a known effect of MDMA use, where users may experience distortions in perception. Methylenedioxy-methamphetamine (MDMA) is known to cause perceptual changes, including hallucinations.

A. Calmly ask the client if he would like to listen to some music. B. Turn the water on and ask the client to test the temperature. C. Firmly tell the client that good hygiene is important. D. Obtain assistance to place mitten restraints on the client.

Correct Answer is A

Explanation

Choice A rationale:

It is essential for the nurse to employ non-pharmacological interventions to manage behavioral issues in clients with Alzheimer's disease. Offering to play music is a suitable approach to distract and soothe the agitated client. Music can have a calming effect and may help reduce anxiety and agitation in clients with dementia. It is a safe and non-invasive intervention that respects the client's autonomy and preferences.

Choice B rationale:

Turning the water on and asking the client to test the temperature (choice B) may not be an appropriate initial response. This action may increase the client's agitation as it involves immediate physical contact and may not address the underlying issue of the client's distress.

Choice C rationale:

Firmly telling the client that good hygiene is important (choice C) is not a recommended approach. Using a firm tone or being authoritative can escalate the client's agitation and may not effectively address the behavioral issue. It's important to use a calm and respectful approach when caring for clients with Alzheimer's disease.

Choice D rationale:

Obtaining assistance to place mitten restraints on the client (choice D) should not be the first choice. Restraints should only be used as a last resort when other methods have failed, and they should be used in accordance with institutional policies and guidelines. Restraints can have adverse physical and psychological effects and should be avoided whenever possible.

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A nurse is receiving change-of-shift report on four clients.Which of the following clients should the nurse plan to see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxy-methamphetamine. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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A nurse is receiving change-of-shift report on four clients.
Which of the following clients should the nurse plan to see first?