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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Heparin prevents clotting during dialysis but doesn’t reduce hemoglobin or hematocrit directly. It’s not a primary cause of anemia in renal failure, unlike erythropoietin deficiency.
Choice B reason: Kidneys in chronic renal failure fail to produce erythropoietin, a hormone stimulating red blood cell production, leading to low hemoglobin and hematocrit, the key cause here.
Choice C reason: Minor blood loss occurs in dialysis, but it’s not the primary reason for chronic anemia. Erythropoietin deficiency from renal failure has a greater impact on counts.
Choice D reason: Poor protein intake affects overall health but isn’t the main driver of anemia in renal failure. Erythropoietin loss from kidney dysfunction is the dominant factor.
Correct Answer is A
Explanation
Choice A reason: Untreated hypothyroidism progresses to myxedema, a severe state with slowed metabolism causing fatigue, cold intolerance, constipation, and hair loss from low thyroid hormone.
Choice B reason: Hypocalcemia results from hypoparathyroidism, not hypothyroidism, which affects metabolism, not calcium regulation directly, so it’s unrelated to these symptoms.
Choice C reason: Pericarditis may occur in severe hypothyroidism late, but it’s not the primary complication; myxedema encompasses the broader metabolic decline seen here.
Choice D reason: Thyroid crisis (storm) is a hyperthyroid emergency with fever and tachycardia, opposite to hypothyroidism’s slow symptoms like coldness and fatigue.
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