The nurse is caring for the following clients. Which client should the nurse assess first?
A 60-year-old client who has end-stage renal disease with a creatinine of 5.1
A 50-year-old client who has chronic pancreatitis and is reporting a pain level of 6 out of 10
A 54-year-old client with cirrhosis and jaundice who is reporting itchiness and drowsiness
A 47-year-old client with esophageal varices and influenza and has been coughing for 30 minutes
The Correct Answer is D
Choice A reason: Creatinine 5.1 in ESRD is chronic, not acute, and stable unless symptomatic; it’s less urgent than potential bleeding risks in other clients.
Choice B reason: Pain (6/10) in pancreatitis is significant but not immediately life-threatening compared to airway or bleeding risks, manageable with scheduled interventions.
Choice C reason: Itchiness and drowsiness in cirrhosis suggest liver dysfunction, concerning but not acute threats like variceal rupture, prioritizing more critical symptoms.
Choice D reason: Coughing with esophageal varices risks rupture and massive bleeding, a life-threatening emergency, making this client the priority for immediate assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Bradycardia occurs in hypothyroidism; Graves’ disease, hyperthyroidism, speeds metabolism, causing tachycardia, not slowed heart rate, during exacerbation.
Choice B reason: Heat intolerance in Graves’ disease results from excess thyroid hormone accelerating metabolism, raising body temperature, a hallmark of hyperthyroidism flares.
Choice C reason: Weight gain aligns with hypothyroidism’s slowed metabolism; Graves’ causes weight loss from increased calorie burning, opposite to this finding.
Choice D reason: Lethargy reflects hypothyroidism’s energy drop; Graves’ exacerbation increases metabolism, leading to restlessness or fatigue from overactivity, not lethargy.
Correct Answer is A
Explanation
Choice A reason: Celiac disease requires a gluten-free diet to prevent malabsorption, ensuring nutrient uptake for growth, the priority in a child to support development long-term.
Choice B reason: Celiac crisis, severe diarrhea, is rare post-diagnosis with dietary control; preventing it is secondary to establishing a sustainable diet for ongoing health.
Choice C reason: Adjusting to dietary restrictions supports compliance but follows initial education on a gluten-free diet, which is foundational for managing celiac disease effectively.
Choice D reason: Respiratory issues aren’t linked to celiac disease, which affects the gut; this option is irrelevant, as complications are gastrointestinal, not pulmonary.
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