A nurse receives report on four clients. The nurse should first collect data about the client who has which of the following?
A decreased level of consciousness and vomiting
Cellulitis accompanied by a low-grade fever
A pain rating of 7 on a scale from 0 to 10 after receiving analgesia 30 min ago
Type 2 diabetes mellitus and a blood glucose level of 160 mg/dL
The Correct Answer is A
A. A decreased level of consciousness and vomiting may indicate a potentially serious condition such as increased intracranial pressure, electrolyte imbalance, or metabolic disorder. Immediate assessment and intervention are necessary to determine the cause and provide appropriate treatment.
B. Cellulitis accompanied by a low-grade fever is concerning but may not require immediate attention compared to a decreased level of consciousness and vomiting.
C. A pain rating of 7 after receiving analgesia 30 minutes ago is important to address, but it may not be as urgent as assessing a client with a decreased level of consciousness and vomiting.
D. A blood glucose level of 160 mg/dL in a client with type 2 diabetes mellitus may require monitoring and intervention, but it may not be as urgent as assessing a client with a decreased level of consciousness and vomiting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Name and medical record number: This information is unique to each individual and is used to accurately identify patients in healthcare settings, including newborns.
B. Birth date and mother's name: While important for identification, this information alone may not be sufficient to accurately identify a newborn, especially in situations where there may be multiple newborns with similar birth dates or mothers with the same name.
C. Age and diagnosis: Age and diagnosis are important clinical information but are not typically used as primary identifiers for medication administration.
D. Footprints and identification number: While footprints and identification numbers may be used as supplemental identifiers, they are not as reliable or commonly used as name and medical record number for medication administration.
Correct Answer is D
Explanation
A. Children whose parents have college degrees may have more access to resources and support systems, potentially reducing the risk of physical abuse.
B. Children who were born after 38 weeks of gestation do not inherently have an increased risk of physical abuse based solely on gestational age at birth.
C. Children whose parents are married may have more stability in their family environment, potentially reducing the risk of physical abuse.
D. Children who live in crowded homes may experience increased stress and tension, leading to a higher risk of physical abuse due to the potential for conflict and limited space.
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