The nurse plans care for a client who reports avoiding people because of having scabies and difficulty walking. Which statement does the nurse document as the client's greatest concern?
Potential for falls
Potential for injury
Potential for loneliness
Potential for self-neglect
The Correct Answer is C
The client's statement of avoiding people because of having scabies and difficulty walking indicates that the client may be experiencing social isolation and loneliness. Loneliness is a significant concern for clients as it can lead to depression, anxiety, and other negative health outcomes. The other options, such as the potential for falls, injury, and self-neglect, may also be concerns for the client but are not indicated as the greatest concern in this scenario based on the information provided. Therefore, the nurse should document the client's greatest concern as the potential for loneliness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","F"]
Explanation
An increase in blood pressure (BP) from 112/68 mm Hg to 122/80 mm Hg indicates an improvement in hemodynamic status, as it shows that the client's blood vessels are constricting to maintain BP and tissue perfusion. f) An increase in urine output from 18 mL/hour to 45 mL/hour indicates an improvement in renal function and fluid balance, which is important for maintaining hemodynamic stability. c) An increase in serum potassium level from 5 mEq/L (5 mmol/L) to 5.4 mEq/L (5.4 mmol/L) indicates an improvement in electrolyte balance, which is important for maintaining proper cardiac function and hemodynamic stability.
Option b) Serum sodium decreased from 146 mEq/L (146 mmol/L) to 138 mEq/L (138 mmol/L) is not a finding that indicates improvement in hemodynamic status. Hyponatremia or low serum sodium levels can cause fluid shifts in the body leading to altered mental status, seizures, and cerebral edema, among other complications. However, the given information does not suggest that the client has hyponatremia or that their hyponatremia has improved.
Option d) Urine output averaging 18 mL/hour is not an improvement, and it may indicate renal insufficiency or failure, which can lead to fluid overload and hemodynamic instability.
Option e) Bowel sounds in all four quadrants indicate normal bowel motility, which is important for proper digestion and absorption of nutrients but does not directly indicate an improvement in hemodynamic status.
Correct Answer is C
Explanation
The client's statement of avoiding people because of having scabies and difficulty walking indicates that the client may be experiencing social isolation and loneliness. Loneliness is a significant concern for clients as it can lead to depression, anxiety, and other negative health outcomes. The other options, such as the potential for falls, injury, and self-neglect, may also be concerns for the client but are not indicated as the greatest concern in this scenario based on the information provided. Therefore, the nurse should document the client's greatest concern as the potential for loneliness.
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