The nurse is receiving morning report on several clients with diseases causing inflammation. What client is the priority for the nurse to assess first?

A client with cholecystitis who is nauseous when they eat fatty foods.

A client with bronchitis who has a productive cough.

A client with appendicitis who has a rigid abdomen and a temperature.

A client with nephritis and a urine output of 30mL/hour.

Answer and Explanation

The Correct Answer is C

A. Nausea with fatty foods is expected in cholecystitis and does not indicate immediate life-threatening complications.

B. A productive cough in bronchitis requires monitoring and supportive care, but it is not the most urgent concern.

C. Rigid abdomen and fever in appendicitis indicate peritonitis, a surgical emergency. This client is at highest risk for sepsis and requires immediate assessment and intervention.

D. Urine output of 30 mL/hour is low but not immediately life-threatening compared to peritonitis; it requires monitoring and possible intervention but is less urgent.

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Correct Answer is ["A","B","D","F","G"]

Explanation

A. A low-stimulation environment helps reduce discomfort and agitation, which is important for clients with meningitis.

B. Assisting with a lumbar puncture is essential for confirming the diagnosis and guiding treatment.

C. The meningococcal vaccine is preventive, not a treatment for active infection. Antibiotics are the primary treatment.

D. Intravenous antibiotics should be initiated immediately to treat bacterial meningitis and reduce morbidity and mortality.

E. While assessing neurologic status is important, daily assessment alone is insufficient; continuous monitoring and early interventions are priority.

F. Seizure precautions are important because meningitis can increase the risk of seizures due to irritation of the meninges.

G. Droplet precautions are necessary to prevent transmission of Neisseria meningitidis, which is highly contagious.

A. Monospot test B. MRI of the ear C. Lumbar puncture D. Audiology consult

Correct Answer is D

Explanation

A. A Monospot test is used to detect infectious mononucleosis, which is unrelated to chronic ear infections.

B. MRI is generally reserved for evaluating structural abnormalities, tumors, or complications, not routine chronic otitis media.

C. Lumbar puncture is used to diagnose central nervous system infections or conditions like meningitis, not ear infections.

D. Chronic otitis media can lead to hearing loss or speech delays. An audiology consult is appropriate to assess the child’s hearing and determine if further intervention, such as hearing aids or surgical options, is needed.

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The nurse is receiving morning report on several clients with diseases causing inflammation. What client is the priority for the nurse to assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","D","F","G"]

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Correct Answer is D

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