A nurse enters a client’s room to answer the call light and finds the client on the bathroom floor. What should be the nurse’s initial action?
Assist the client back into bed.
Notify the client’s provider.
Inform the client’s family member.
Obtain the client’s vital signs.
The Correct Answer is D
The correct answer is choice D.
Choice A rationale:
Assisting the client back into bed is not the initial action. Moving the client without assessing their condition could potentially cause harm.
Choice B rationale:
Notifying the client’s provider is important, but it should be done after assessing the client’s condition to provide accurate information.
Choice C rationale:
Informing the client’s family member is not the immediate priority. The nurse should first ensure the client’s safety and assess their condition.
Choice D rationale:
Obtaining the client’s vital signs is the initial action. This helps assess the client’s current condition and determine if there are any immediate medical needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Tenderness to touch is a common finding in wounds healing by secondary intention. It's often due to inflammation, which is a normal part of the healing process. The inflammation brings in cells and substances that promote healing. However, increased tenderness, especially when accompanied by other signs of infection, should be reported.
Choice B rationale:
A halo of erythema on the surrounding skin is a sign of infection. This is a serious complication that can delay healing and lead to further complications. The erythema indicates that the infection is spreading beyond the wound edges and needs prompt attention.
Choice C rationale:
Drainage of serosanguineous fluid is also common in wounds healing by secondary intention. This fluid is a mixture of serum (clear yellowish fluid) and blood. It's a sign that the wound is cleaning itself and new tissue is forming. While excessive drainage or a change in color or odor could signal a problem, drainage itself is not necessarily a cause for concern.
Choice D rationale:
Pink, shiny tissue with a granular appearance is a sign of healthy granulation tissue. This is a type of tissue that forms during the healing process. It's rich in blood vessels and collagen, which are essential for wound healing. The presence of granulation tissue indicates that the wound is healing well.
Correct Answer is D
Explanation
Choice A rationale:
Hypovolemic shock is a type of shock that occurs when there is a significant loss of blood or fluid volume, leading to decreased cardiac output and tissue perfusion. This can be caused by severe bleeding, dehydration, burns, or other conditions that result in fluid loss. While anaphylaxis can involve some fluid shifts, it is not primarily characterized by a loss of blood or fluid volume.
Key features of hypovolemic shock that distinguish it from anaphylactic shock include:
Prominent signs of dehydration: Dry skin and mucous membranes, decreased urine output, sunken eyes, and poor skin turgor.
Hemodynamic changes: Tachycardia, narrow pulse pressure, and cold extremities due to vasoconstriction to maintain blood pressure.
Laboratory findings: Elevated hematocrit and blood urea nitrogen (BUN) levels, indicating hemoconcentration and decreased kidney perfusion.
Choice B rationale:
Obstructive shock is a type of shock that occurs when there is an obstruction to blood flow, preventing adequate circulation to the body's tissues. This can be caused by conditions such as pulmonary embolism, cardiac tamponade, or tension pneumothorax. Anaphylaxis does not involve a physical obstruction to blood flow.
Key features of obstructive shock that distinguish it from anaphylactic shock include:
Evidence of the underlying obstruction: Jugular venous distension (cardiac tamponade), muffled heart sounds (cardiac tamponade), or respiratory distress (pulmonary embolism or tension pneumothorax).
Distinctive hemodynamic changes: Equalization of diastolic pressures between the right and left ventricles (cardiac tamponade).
Specific imaging findings: Enlarged cardiac silhouette on chest X-ray (pericardial effusion), filling defects in the pulmonary arteries on CT angiography (pulmonary embolism), or hyperexpanded lung fields with a deviated trachea on chest X-ray (tension pneumothorax).
Choice C rationale:
Cardiogenic shock is a type of shock that occurs when the heart is unable to pump enough blood to meet the body's needs. This can be caused by conditions such as heart attack, heart failure, or cardiomyopathy. Anaphylaxis does not primarily involve a failure of the heart's pumping function.
Key features of cardiogenic shock that distinguish it from anaphylactic shock include:
Evidence of heart failure: Pulmonary edema, elevated jugular venous pressure, and a third heart sound (S3 gallop).
Electrocardiogram (ECG) changes: ST-segment elevation or depression, Q waves, or other signs of myocardial ischemia or infarction.
Elevated cardiac enzymes: Troponin and creatine kinase-MB (CK-MB) levels, indicating heart muscle damage.
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