The nurse has finished receiving shift report at 7:30 AM. Which client should the nurse assess first?
The client diagnosed with rheumatoid arthritis who complains of morning joint stiffness.
The client who needs to receive a scheduled 8 AM IV corticosteroid.
The client with scleroderma who has an episode of dyspnea during the night shift.
The client suspected of an acute gout attack who is scheduled for an arthrocentesis.
The Correct Answer is C
Choice A rationale
Rheumatoid arthritis involves an autoimmune response where the body attacks the synovial membrane, causing chronic inflammation. Morning stiffness is a classic, expected symptom of this disease caused by joint congestion and inactivity during sleep. While uncomfortable for the patient, it does not represent an acute physiological crisis requiring immediate intervention over other potentially unstable patients. The nurse can address this after checking more critical respiratory or vascular concerns.
Choice B rationale
Corticosteroids are frequently used to manage inflammatory or autoimmune conditions by suppressing the immune system and reducing cytokine production. An 8 AM scheduled dose is a routine medication administration task. While maintaining the medication schedule is important for therapeutic blood levels, it is not an emergency. Administering a medication thirty minutes after shift report is a standard nursing duty that follows the assessment of unstable patients according to triage principles.
Choice C rationale
Scleroderma or systemic sclerosis can lead to pulmonary fibrosis and pulmonary hypertension as collagen overproduction affects lung tissue and vasculature. Dyspnea, especially a new or recent episode, indicates potential respiratory compromise or cardiac involvement which is life-threatening. Normal respiratory rates are 12 to 20 breaths per minute. Any patient showing signs of breathing difficulty must be prioritized first to ensure adequate oxygenation and to prevent rapid clinical decline or respiratory failure.
Choice D rationale
Gout is caused by the accumulation of urate crystals in the joint, leading to intense inflammatory pain. Arthrocentesis is a procedure used to aspirate synovial fluid for diagnosis or to relieve pressure. While an acute gout attack is very painful, it is not immediately life-threatening. The patient is stable and awaiting a scheduled diagnostic procedure. The nurse should assess this patient after addressing the client with dyspnea but before routine medication administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Amiodarone is a class III antiarrhythmic medication primarily utilized for ventricular and supraventricular tachycardias. Its common side effect profile includes pulmonary toxicity, thyroid dysfunction, and corneal microdeposits. Unlike certain other cardiac medications, it is not traditionally classified as a primary ototoxic agent. It does not typically cause significant damage to the hair cells of the cochlea or the vestibulocochlear nerve during standard therapeutic use.
Choice B rationale
Loop diuretics, such as furosemide, are well-documented ototoxic agents. These medications inhibit the sodium-potassium-chloride symporter in the thick ascending limb of the loop of Henle and can also alter the electrolyte balance in the stria vascularis of the inner ear. This disruption in endolymph composition can lead to temporary or permanent hearing loss and tinnitus, particularly when administered rapidly or at high doses via intravenous routes.
Choice C rationale
Nonsteroidal anti-inflammatory drugs, or NSAIDs, including aspirin and ibuprofen, can cause ototoxicity when taken in high doses. These agents inhibit prostaglandin synthesis and can decrease blood flow to the cochlea, leading to cellular metabolic stress. Patients frequently report tinnitus, which is often reversible once the medication is discontinued. Monitoring is essential as chronic high-dose therapy can result in a more persistent sensorineural hearing impairment.
Choice D rationale
Vancomycin is a potent glycopeptide antibiotic used for serious gram-positive infections. It is recognized for its potential to cause nephrotoxicity and ototoxicity, especially when serum trough levels exceed the normal range of 15 to 20 mcg/mL. The mechanism involves direct damage to the auditory nerve or the cochlear hair cells. Risk increases significantly when combined with other ototoxic drugs, requiring close monitoring of hearing and renal function.
Choice E rationale
Cimetidine is a histamine H2-receptor antagonist used to reduce gastric acid secretion in conditions like peptic ulcer disease and GERD. While it has several systemic side effects and drug interactions due to cytochrome P450 inhibition, it is not classified as an ototoxic medication. It does not typically interfere with the delicate neurosensory structures of the ear or the fluid dynamics necessary for normal auditory processing.
Correct Answer is A
Explanation
Choice A rationale
Cataracts involve the clouding of the crystalline lens of the eye, which normally focuses light onto the retina. As the lens becomes opaque due to protein clumping, light is scattered rather than focused, resulting in blurry or hazy vision. This progressive condition affects visual acuity and makes objects appear as if the person is looking through a frosted or fogged-up window, which is a classic clinical manifestation of cataract development.
Choice B rationale
The presence of dark spots moving across the visual field is usually indicative of vitreous floaters or potentially a retinal detachment. These spots are caused by shadows cast on the retina by microscopic fibers within the vitreous humor. While common with aging, they are not a primary symptom of cataracts, which focus on the clarity of the lens itself rather than the integrity of the vitreous or the posterior segment of the eye.
Choice C rationale
The inability to see objects from the side of the eyes refers to a loss of peripheral vision, which is a hallmark sign of glaucoma. In glaucoma, increased intraocular pressure damages the optic nerve, typically starting with the outer fibers that provide side vision. Cataracts generally cause a global decrease in clarity across the entire visual field rather than a specific loss of peripheral sight while maintaining central vision as seen in glaucoma.
Choice D rationale
Losing the ability to see things in the middle part of the eyes is characteristic of macular degeneration. The macula is responsible for sharp, central vision required for activities like reading or driving. Damage to this area causes a central blind spot or blurriness. Cataracts, conversely, create a generalized haze. While a cataract can be central, the specific complaint of losing central vision specifically points more toward retinal or macular pathology.
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