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 thrombocytopenia and reports a nosebleed
A client who has left-sided paralysis and slurred speech from a prior stroke
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%
The Correct Answer is D
Choice A rationale: A client with thrombocytopenia reporting a nosebleed may need intervention, but it is not an immediate concern unless severe bleeding is present.
Choice B rationale: A client with left-sided paralysis and slurred speech from a prior stroke may need attention, but their airway and oxygenation should take precedence.
Choice C rationale: A client with multiple sclerosis reporting ataxia and vertigo may need assessment and care, but their symptoms are not indicative of an immediate life-threatening situation.
Choice D rationale: A client with chronic obstructive pulmonary disease and an oxygen saturation of 89% requires immediate attention, as this indicates potential respiratory distress and hypoxemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Placing a large-face clock in the client's bedroom helps the individual with Alzheimer's disease maintain orientation to time, promoting a sense of familiarity and reducing confusion.
Choice B rationale: While a monthly calendar could be helpful, a large-face clock is a more direct and immediate way to help the client understand the current time and reduce disorientation.
Choice C rationale: Covering electrical outlets is important for safety but may not directly address the client's cognitive needs associated with Alzheimer's disease.
Choice D rationale: Keeping the client's bedroom dark at night might contribute to increased confusion and disorientation for someone with Alzheimer's disease.
Correct Answer is B
Explanation
Choice A rationale: Incisional pain is localized pain at the site of the surgical incision and does not represent referred pain.
Choice B rationale: Referred pain occurs when pain is felt at a site distant from its origin. In the case of pancreatitis, pain may be referred to the left shoulder.
Choice C rationale: Generalized abdominal pain in a client with peritonitis is not an example of referred pain.
Choice D rationale: Substernal chest pain in a client with angina is a manifestation of localized pain related to the heart.
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