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 A
Explanation
A history of inflammatory bowel disease, such as Crohn's disease or ulcerative colitis, is a risk factor for colorectal cancer . These conditions cause chronic inflammation and damage to the cells lining the colon and rectum, which may increase the likelihood of DNA mutations and cancer development. A diet high in fiber may help lower the risk of colorectal cancer by promoting regular bowel movements and reducing exposure to toxins. Age 46 years is not a significant risk factor, as most cases of colorectal cancer occur in people older than 50. BMI of 24 is within the normal range and does not indicate obesity, which is another risk factor for colorectal cancer.
Correct Answer is B
Explanation
Abdominal distension and firmness indicate increased intra-abdominal pressure, which can compromise blood flow to the bowel and cause ischemia, necrosis, or perforation.
The nurse should report this finding to the provider and assess for signs of shock or peritonitis.
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