A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first?
A client who has multiple sclerosis and reports ataxia and vertigo
A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89%
A client who has left-sided paralysis and slurred speech from a prior stroke
A client who has thrombocytopenia and reports a nosebleed
The Correct Answer is D
The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first, as this client has the most urgent problem and is at risk of hemorrhage. Thrombocytopenia is a condition characterized by a low platelet count, which impairs blood clotting and increases bleeding tendencies. The other clients have chronic or stable conditions that require ongoing monitoring and intervention, but are not as urgent as the client with the nosebleed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Weight gain 1.1 kg (2.4 lb) in 24 hours indicates fluid retention and possible volume overload, which can worsen kidney function and cause complications such as hypertension, pulmonary edema, and heart failure. The nurse should report this finding to the provider and monitor the client's vital signs, fluid intake and output, and electrolyte levels.
Creatinine 0.8 mL/dL is within the normal range for adults and does not indicate kidney impairment. Peripheral pulses 2+ bilaterally are normal and do not suggest any vascular problems. Urine specific gravity 1.045 is slightly high but not abnormal for a client with acute kidney failure, as it reflects the reduced ability of the kidneys to dilute urine.
Correct Answer is B
Explanation
To assess a client for a positive Chvostek’s sign, the nurse should tap gently on the cheek, specifically two centimeters in front of the ear, over the facial nerve (also known as CN VII). This test is used to check for hypocalcemia, a condition that can lead to tetany, which is the involuntary contraction of muscles. A twitch of the facial muscles in response to this tapping indicates a positive Chvostek’s sign. This is particularly relevant following a thyroidectomy, as the procedure can indirectly affect the parathyroid glands, potentially leading to hypocalcemia
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