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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While reassurance is important, simply telling the client that she will adjust to changes to her body may minimize her concerns and not adequately address her emotional needs. It's important to offer support and provide resources to help the client cope with potential changes.
B. While an occupational therapist may be able to provide valuable support, their role may not specifically address the client's concerns about body image changes related to breast cancer treatment.
C. Reach to Recovery is a program offered by the American Cancer Society that connects newly diagnosed breast cancer patients with trained volunteers who have experienced breast cancer themselves. These volunteers can offer support, guidance, and practical tips for coping with the physical and emotional challenges of breast cancer diagnosis and treatment. Initiating a referral to this program can provide the client with valuable support from someone who has been through a similar experience.
D. While surgery may be an option for restoring the appearance of the breast, it may not fully address the client's concerns about potential changes to her body image. Additionally, not all breast cancer patients undergo surgery or choose reconstructive procedures, so it's important to provide support and resources regardless of the treatment chosen.
Correct Answer is B
Explanation
A. Incorrect. Lip smacking is not typically associated with pain in newborns and may indicate hunger or a self-soothing behavior.
B. Correct. Diaphoresis, or sweating, can be a sign of pain in newborns following circumcision. C. Incorrect. Hypoglycemia refers to low blood glucose levels and is not a direct manifestation of pain.
D. Incorrect. Transient strabismus, or crossed eyes, is not typically associated with pain in newborns and may be a normal variation.
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