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Which nursing problem has the highest priority when planning care for a client with osteomalacia?

Altered tissue perfusion.

Sleep pattern disturbance.

Risk for injury.

Risk of infection.

Answer and Explanation

The Correct Answer is C

Choice A reason: Altered tissue perfusion is important but not the primary concern in osteomalacia.

Choice B reason: Sleep pattern disturbance may occur but is not the highest priority.

Choice C reason:

The correct answer is c) because clients with osteomalacia have weakened bones and are at high risk for fractures, making injury prevention the highest priority.

Choice D reason: Risk of infection is important but not the primary concern in osteomalacia.

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Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because auscultating bowel sounds can help assess for the return of gastrointestinal function and identify potential complications such as ileus, which can cause abdominal pressure and nausea.

Choice B reason: Ambulating the client is important for postoperative recovery but does not directly address the symptoms of abdominal pressure and nausea.

Choice C reason: Palpating the abdomen is also important but should be done after auscultation to avoid altering bowel sounds.

Choice D reason: Measuring urine output is important for monitoring renal function but does not directly address the symptoms of abdominal pressure and nausea.

A. Increase frequency of BP assessments. B. Encourage the client to breathe deeply. C. Check the abdominal surgical dressing. D. Review the client's baseline BP trends.

Correct Answer is C

Explanation

Choice A reason: Increasing the frequency of BP assessments is important to monitor the client's condition, but it does not address the potential cause of the drop in blood pressure.

Choice B reason: Encouraging the client to breathe deeply is useful for overall respiratory function but does not address the specific issue of the dropping blood pressure.

Choice C reason:

The correct answer is c) because checking the abdominal surgical dressing can help identify if there is postoperative bleeding or other complications at the surgical site, which could be causing the drop in blood pressure.

Choice D reason: Reviewing the client's baseline BP trends provides useful information but does not address the immediate potential cause of the blood pressure change.

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Which nursing problem has the highest priority when planning care for a client with osteomalacia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?

Correct Answer is A

Explanation

One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

Correct Answer is C

Explanation

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