A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?

A client who is postoperative and reports intermittent nausea

A client whose blood pressure is 160/90 mm Hg and reports a headache

A client who is scheduled for surgery in 2 hr

A client who is postoperative and has a Jackson-Pratt drain

Answer and Explanation

The Correct Answer is B

Hypertensive crisis is a severe increase in blood pressure that can lead to organ damage or other complications. Prompt assessment and intervention are necessary to prevent further escalation of blood pressure and potential complications.

While all the clients mentioned require attention, the client with elevated blood pressure and a headache poses a higher immediate risk. The nurse should assess the client's blood pressure, evaluate for signs of target organ damage, and initiate appropriate interventions, which may include administering antihypertensive medications as prescribed and monitoring closely for any changes in the client's condition.

The client who is postoperative and reports intermittent nausea can be assessed and managed after addressing the client with the elevated blood pressure and headache.

The client scheduled for surgery in 2 hours can be addressed according to the scheduled timeline.

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Correct Answer is ["C","D","E","F"]

Explanation

Case management can be beneficial in situations involving assault to help coordinate and provide ongoing support and resources for the client. This intervention is appropriate in this scenario.

Ensuring a safe and private environment is crucial to protect the client's confidentiality and provide a supportive atmosphere during this difficult time. This intervention is necessary. Since the client reports being assaulted and has sore genitals, it is important to consider the risk of sexually transmitted infections (STIs). Administering STI prophylaxis can help prevent potential infections.

The client may benefit from additional support services such as counseling or support groups. Providing resources for local support services can help the client access the necessary help and support they need.

Contacting children and youth services is not applicable in this scenario as the client is a full-time college student and not a child or youth.

While the client mentioned drinking, it is not explicitly stated that they have an alcohol addiction or problem. Therefore, providing resources for Alcoholics Anonymous may not be the most appropriate intervention at this time.

A. "Our child is able to complete his homework on time B. “Our child has lost some weight since his last appointment." C. “Our child has increased his daily caloric intake." D. "Our child has a better grasp of reality"

Correct Answer is A

Explanation

ADHD (Attention-Deficit/Hyperactivity Disorder) is characterized by symptoms such as difficulty sustaining attention, impulsivity, and hyperactivity. Methylphenidate is a commonly prescribed medication for ADHD that helps improve focus, attention, and impulse control.

The ability to complete homework on time suggests improved focus and attention, which are positive effects of methylphenidate in managing ADHD symptoms. It indicates that the medication is helping the child stay on task and concentrate better, leading to improved academic performance.

"Our child has lost some weight since his last appointment" suggests a potential side effect of methylphenidate, which can cause appetite suppression and weight loss.

"Our child has increased his daily caloric intake" might be a response to the weight loss side effect, but it does not directly indicate the effectiveness of the medication.

"Our child has a better grasp of reality" is a subjective statement that does not specifically relate to ADHD symptoms or the expected effects of methylphenidate.

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A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","D","E","F"]

Explanation

A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?

Correct Answer is A

Explanation

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

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