A client is unresponsive.
Which of the following nursing actions is the priority?
Assessing the client's level of pain.
Checking the client's airway and breathing.
Documenting the client's Glasgow Coma Scale score.
Obtaining a detailed neurological history from family.
The Correct Answer is B
Choice A rationale
Assessing the client's level of pain is important in many situations, but in an unresponsive client, airway and breathing take immediate priority. An unresponsive client cannot communicate pain, and addressing potentially life-threatening issues like airway obstruction or respiratory arrest is paramount.
Choice B rationale
Checking the client's airway and breathing is the priority nursing action for an unresponsive client. Unresponsiveness can indicate a critical condition that may compromise the client's ability to maintain a patent airway or breathe effectively. Ensuring a clear airway and adequate ventilation are essential for preventing hypoxia and death. This aligns with the ABC (Airway, Breathing, Circulation) approach to emergency care.
Choice C rationale
Documenting the client's Glasgow Coma Scale (GCS) score is important for assessing the level of consciousness and neurological function. However, in an unresponsive client, ensuring airway and breathing precedes a detailed neurological assessment. The GCS can be assessed after immediate life-threatening issues are addressed.
Choice D rationale
Obtaining a detailed neurological history from family can provide valuable information, but it is not the priority in the immediate management of an unresponsive client. Addressing the client's immediate physiological needs, such as airway and breathing, takes precedence over gathering historical information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A rationale
Jugular distention is a classic sign of right-sided heart failure. In right-sided heart failure, the right ventricle is unable to effectively pump blood to the lungs, leading to increased pressure in the right atrium and systemic venous circulation. This increased venous pressure causes the jugular veins in the neck to become distended, especially when the client is in a semi-recumbent position.
Choice B rationale
Frothy sputum is a common finding in left-sided heart failure. When the left ventricle fails to pump blood effectively, pressure increases in the left atrium and pulmonary veins. This increased pressure forces fluid into the alveoli, leading to pulmonary edema. The fluid mixes with air in the alveoli, producing a characteristic frothy, often pink-tinged sputum.
Choice C rationale
Dependent edema, such as swelling in the legs and ankles, is more characteristic of right-sided heart failure. It occurs due to the increased systemic venous pressure, which causes fluid to accumulate in the dependent areas of the body due to gravity. While left-sided heart failure can eventually lead to systemic congestion and edema, it is not the primary early finding.
Choice D rationale
Nocturnal polyuria, or increased urination at night, is a common symptom of left-sided heart failure. During the day, fluid accumulates in the dependent extremities due to decreased cardiac output and increased venous pressure. When the client lies down at night, this fluid is redistributed to the central circulation, increasing renal blood flow and leading to increased urine production.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Chronic cough is a hallmark symptom of COPD, resulting from the persistent inflammation and irritation of the airways. The excessive mucus production and damage to the cilia impair the mucociliary clearance mechanism, leading to a persistent need to cough to clear the airways.
Choice B rationale
Sputum production is another common manifestation of COPD. The chronic inflammation in the airways stimulates an overproduction of mucus by the goblet cells. This increased mucus, often thick and tenacious, needs to be expectorated through coughing.
Choice C rationale
Dyspnea, or shortness of breath, is a progressive symptom of COPD. It arises from the airflow limitation caused by airway narrowing, mucus hypersecretion, and destruction of the lung parenchyma (emphysema). Initially, it occurs with exertion but worsens over time to occur even at rest.
Choice D rationale
Nausea is not typically a primary manifestation of COPD. While some individuals with severe respiratory distress might experience nausea, it is not considered a common or direct symptom of the underlying lung disease itself.
Choice E rationale
Chest pain is not a typical manifestation of uncomplicated COPD. While individuals with COPD can experience chest pain due to other comorbidities, such as cardiac issues or musculoskeletal problems, it is not a direct symptom of the chronic airflow limitation characteristic of COPD.
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