A nurse performs a head-to-toe assessment on a newly admitted client. Data analysis reveals temperature 100.94°F (38.3°C), blood pressure 82/58 mm Hg, 02 saturation 95% on room air, productive cough, lethargy, diaphoresis, WBC 15,000 mm3, hemoglobin 9 g/dl, and hematocrit 29%. Based on the analysis of the data, which of the following client concerns is a priority?

hypoxia

anemia

hypotension

Pneumonia

Answer and Explanation

The Correct Answer is C

A) Hypoxia: Although the client's oxygen saturation is slightly decreased at 95% on room air, it is not critically low. Hypoxia could be a concern, but it is secondary to other more immediate issues, such as hypotension, that might be causing the low oxygen saturation.
B) Anemia: The client’s hemoglobin and hematocrit levels are low, indicating anemia. While anemia is a significant concern, it does not pose an immediate threat compared to hypotension, which can lead to more severe complications if not addressed promptly.
C) Hypotension: The client’s blood pressure is notably low at 82/58 mm Hg. Hypotension can lead to inadequate perfusion of vital organs and may be a result of or contribute to other issues such as sepsis or significant blood loss. Immediate attention to correcting hypotension is crucial to prevent further complications.
D) Pneumonia: The client presents with symptoms suggestive of pneumonia, including a productive cough, fever, and elevated white blood cell count. While pneumonia is a critical condition that requires treatment, addressing hypotension is a more urgent priority as it directly impacts the client's circulatory stability and overall well-being.

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Correct Answer is B

Explanation

A) Neither talk nor comprehend: This description does not accurately characterize receptive aphasia. Receptive aphasia, also known as Wernicke's aphasia, primarily affects comprehension, while speech production may remain intact. Patients with this condition may speak fluently but have difficulty understanding spoken or written language.
B) Talk but do not comprehend: Receptive aphasia is characterized by the ability to produce speech fluently but with impaired comprehension. Patients can talk and may produce coherent-sounding speech, but they struggle to understand others' speech and may not grasp the meaning of what they are saying.
C) No alteration in speech and language: Receptive aphasia involves specific alterations in speech and language, particularly in comprehension. While speech may be fluent, the content often lacks meaning or coherence, and comprehension is significantly impaired.
D) Comprehend but not able to talk: This description aligns more with expressive aphasia (Broca's aphasia), where patients have difficulty producing speech but generally retain comprehension abilities. Receptive aphasia affects comprehension while allowing relatively intact speech production.

Correct Answer is "{\"xRanges\":[41.828125,50.828125],\"yRanges\":[132.5,141.5]}"

Explanation

The P wave is the first deflection of the ECG complex, preceding the QRS complex. It is typically a small, rounded, and positive deflection on the ECG.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is diagnosed with Receptive Aphasia. The nurse understands this patient can:

Correct Answer is B

Explanation

A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as the P wave in the ECG complex? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is "{\"xRanges\":[41.828125,50.828125],\"yRanges\":[132.5,141.5]}"

Explanation

A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. Which of the following types of prevention is the nurse demonstrating?

The nurse uses deep palpation of the abdomen to assess the client for presence of an abdominal mass. The client grimaces and grips the hand rails of the bed. Which response by the nurse is best?

A nurse is performing a complete physical examination on a patient. After examining the patient with the Snellen chart, the nurse documented distance vision in both eyes 20/40. The patient asks the nurse what 20/40 means:

Assessment of the client reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?

A client with congestive heart failure presents with edema of the ankles. When conducting a physical examination of this client, the nurse requires a gooseneck lamp for which purpose?

The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg. 02 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

When preparing to test a client for meningeal irritation, which of the following would be most important for the nurse to do first?