The nurse is prioritizing a client's problem list. Which of the following problems should receive the highest priority?
Ineffective Sexuality Pattern
Risk for Social Isolation
Activity Intolerance
Imbalanced Nutrition: less than body requirements
The Correct Answer is D
D. This problem indicates that the client is not receiving adequate nutrition to meet metabolic needs, which can lead to malnutrition and compromised healing. Addressing imbalanced nutrition is crucial for maintaining health and supporting recovery.
A. This problem refers to disturbances in sexual function or satisfaction. While important to address, it is not typically considered a high priority compared to other physiological or safety-related issues unless it B This problem indicates the potential for the client to experience loneliness or social disconnection, which can impact mental and emotional well-being. While addressing social isolation is important for holistic care, it may not be as urgent as issues related to physical health or safety.
C This problem indicates the inability to endure physical activities or exercise due to insufficient physiological or psychological energy. Activity intolerance can be a significant concern post-operatively or in clients with chronic conditions, as it can affect recovery and overall functional ability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1700"]
Explanation
To calculate the time when a new IV bag will be needed, we can divide the total volume left in the bag by the infusion rate.
With 500 ml remaining and an infusion rate of 100 ml per hour, it will take 5 hours for the current bag to be depleted.
Since the report was given at 1200 (which is noon in military time), adding 5 hours brings us to 1700, or 5:00 PM.
Therefore, the nurse should expect to hang a new IV bag at 1700 hours in military time.
Correct Answer is C
Explanation
C. This reflex is an important protective mechanism that prevents objects from entering the throat and causing choking. Assessing the gag reflex before oral care can help ensure the safety of the client, especially if they have difficulty swallowing or are at risk for aspiration.
A. It's important to assess if the client is experiencing any pain, as oral care procedures can sometimes cause discomfort, especially if the client has oral lesions or sensitive gums. However, it is not a priority.
B. Presence of saliva: Saliva is essential for oral health, as it helps to cleanse the mouth and buffer acids produced by bacteria. Assessing the amount of saliva can indicate the overall oral hydration status and potential risk of dry mouth (xerostomia).
D. assessing the condition of the skin around the mouth and on the lips is important. It can reveal issues such as dryness, cracking, lesions, or signs of infection but not directly related to oral care.
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