The nurse is admitting a client who reports symptoms of dyspnea. The nurse notes edema of the upper arms, face, and neck. What is the nurse's priority assessment?

Degree of upper body vasculature observed.

Arm circumference and degree of edema.

Blood pressure and heart rate.

Peripheral sensation and movement of upper extremities.

Answer and Explanation

The Correct Answer is C

A. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.
B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.
C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.
D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.

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Correct Answer is D

Explanation

A. The prone position is not suitable post-craniotomy as it can increase intracranial pressure and may compromise respiratory function.
B. The dorsal recumbent position is not ideal for patients post-craniotomy, as it can hinder optimal intracranial pressure management.
C. The lateral recumbent position is generally avoided immediately after craniotomy to prevent pressure on the surgical site and ensure proper cerebral perfusion.
D. The Semi-Fowler's position helps reduce intracranial pressure, promotes venous drainage, and is generally recommended for post-operative care following a craniotomy.

A. "I will eat three large meals a day to ensure I have energy." B. "A flat lying position allows full lung expansion." C. "I will pace myself with activities with my family." D. "Once a day I will receive pain medication."

Correct Answer is C

Explanation

A. This statement may not be ideal; smaller, more frequent meals can help manage appetite and energy levels better than three large meals, especially for cancer patients who may experience fatigue or nausea.
B. A flat lying position can hinder lung expansion; a more elevated position is generally recommended to facilitate breathing.
C. This statement shows understanding of the need to manage energy levels and not overexert oneself, which is crucial for maintaining stamina during treatment.
D. Pain management typically requires more frequent dosing rather than a once-a-day regimen, depending on the severity of the pain.

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The nurse is admitting a client who reports symptoms of dyspnea. The nurse notes edema of the upper arms, face, and neck. What is the nurse's priority assessment?

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