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 chronic obstructive pulmonary disease and an oxygen saturation of 89%
A client who has multiple sclerosis and reports ataxia and vertigo
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 A
Choice A Reason:
A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% is correct. The nurse should attend to the client with chronic obstructive pulmonary disease and an oxygen saturation of 89% first. Oxygen saturation levels below 90% indicate significant hypoxemia and potential respiratory distress. The client with COPD is at risk for further worsening of their condition due to inadequate oxygenation. Therefore, addressing this client's low oxygen saturation is a priority to ensure their respiratory status is stabilized.
Choice B Reason:
A client who has multiple sclerosis and reports ataxia and vertigo is incorrect. While these symptoms need assessment and care, they are not indicative of an immediate life-threatening situation.
Choice C Reason:
A client who has left-sided paralysis and slurred speech from a prior stroke is incorrect., While this client requires ongoing care, the immediate concern is lower in priority compared to addressing severe hypoxemia.
Choice D Reason:
A client who has thrombocytopenia and reports a nosebleed is incorrect. Although a nosebleed can be concerning due to thrombocytopenia, it is not as immediately critical as addressing severe hypoxemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Decreased bowel sounds: Hyponatremia (low serum sodium levels) primarily affects the nervous system and can lead to neurological symptoms such as confusion, seizures, and headache. It doesn't typically directly affect bowel sounds. Therefore, this option is not the expected finding.
Choice B Reason:
Increased central venous pressure: As I mentioned earlier, hyponatremia can lead to cerebral edema (swelling of the brain) due to the movement of water into cells. This swelling can increase intracranial pressure and, in turn, affect the central venous pressure by impacting blood return to the heart. While the relationship between hyponatremia and central venous pressure might be complex, it's a more relevant consideration compared to the other options provided.
Choice C Reason:
Hyperreflexia: Hyponatremia can lead to changes in brain function and neurological symptoms, including altered reflexes. Hyperreflexia, which is an exaggerated response to stimuli, can indeed be a manifestation of hyponatremia, making this option a potential expected finding.
Choice D Reason:
Contusion: A contusion is a bruise that results from damage to blood vessels beneath the skin. Hyponatremia is not directly related to the formation of contusions. This option is not the expected finding in a client with low serum sodium levels.
Correct Answer is B
Explanation
"I will tell your provider that you do not want to take this medication." - This response does not address the client's concerns and might lead to a confrontational approach.
Choice B Reason:
"Your provider wouldn't prescribe this medication if it weren't necessary." Response B is the most appropriate and therapeutic response in this situation. It acknowledges the client's concerns while also emphasizing the importance of following the provider's prescription. By reassuring the client that the provider's decision to prescribe the medication is based on their assessment and medical judgment, the nurse promotes trust and encourages the client to comply with the treatment plan.
Choice C Reason:
"Most clients feel better after taking the antibiotic." - While true, this response doesn't directly address the client's specific concern and might not alleviate their doubts.
Choice D Reason:
"If you don't take this medication, you will feel worse." - This response might come across as overly negative and could potentially lead to resistance or defensiveness from the client. It's important to approach the situation with empathy and respect for the client's perspective.
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