The practical nurse (PN) is assisting in a community center clinic when four clients simultaneously arrive seeking help. In which order should the PN prioritize care to be provided based on the client needs? (Arrange the client with the highest priority first, on top, and lowest priority last, on botom.)
A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath.
A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness
A 10-year-old child with bleeding lacerations on both knees after falling on the playground
A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.
The Correct Answer is A,B,C,D
A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath.
This client has the highest priority, as he or she may be experiencing an acute asthma atack that can compromise the airway and oxygenation. The PN should assess the client's respiratory status, administer bronchodilators, and monitor for improvement or deterioration.
A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness.
This client has the second highest priority, as he or she may be experiencing hypoglycemia, which is a low blood glucose level that can cause neurologic symptoms such as confusion, seizures, or coma. The PN should check the client's blood glucose level, provide a source of glucose, and monitor for recovery or complications.
A 10-year-old child with bleeding lacerations on both knees after falling on the playground.
This client has the third highest priority, as he or she may have a risk of infection or blood loss from the wounds. The PN should clean and dress the lacerations, apply pressure if needed, and check for signs of infection or inflammation.
A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.
This client has the lowest priority, as he or she does not have a life-threatening or urgent condition, but a psychosocial or emotional issue. The PN should provide comfort and reassurance to the child, change his or her clothes, and explore the possible causes of the incontinence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A, E"},"B":{"answers":"C, E"},"C":{"answers":"C, E"},"D":{"answers":"D, G"}}
Explanation
Colchicine is used in severe acute gout attack to minimize pain at the joint. Colchicine's mechanism of action involves interfering with the inflammatory process by binding to tubulin, a protein essential for the formation of microtubules within cells.
Prednisone is a corticosteroid with anti-inflammatory properties. It reduces inflammation caused by urate crystals.
Naproxen is a nonsteroidal anti-inflammatory drug (NSAID). It interferes with the inflammatory process in gout reducing pain. The use of naproxen and prednisone with alcohol reduces their effectiveness leading to suboptimal pain relief.
Allopurinol is a lipid lowering agent. It prevents the formation of uric acid lowering the deposition of urate crystals at the joint(s). Missing a dose of allopurinol leads to subtherapeutic blood levels and increased risk of acute gout attacks.
Correct Answer is B
Explanation
B. SIADH is characterized by excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. Fluid restriction is a key component of treatment for SIADH to restore serum sodium levels to normal. Maintaining the prescribed fluid restriction is important for preventing further dilution of serum sodium and promoting continued improvement in the client's condition.
A. Withholding the next scheduled dose of treatment may not be appropriate solely based on a mild increase in serum sodium level. While syndrome of inappropriate antidiuretic hormone (SIADH) can lead to hyponatremia (low sodium levels) due to excessive water retention, an increase in serum sodium within a narrow range may not necessarily warrant withholding treatment.
C. Assessing for increasing fluid volume overload may be relevant in the context of managing SIADH and monitoring the client's response to treatment. However, an increase in serum sodium level from 120 mEq/L to 125 mEq/L suggests a trend towards correction of hyponatremia rather than worsening fluid volume overload.
D. Increasing the frequency of neurologic checks to every 2 hours may not be necessary solely based on a mild increase in serum sodium level from 120 mEq/L to 125 mEq/L.
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