A nurse has received a report on a group of clients. Which of the following clients should the nurse assess first?
A client who has type 2 diabetes mellitus with a blood glucose level of 120 mg/dL (normal range: 74-106 mg/dL).
A client who has diabetes insipidus with an intake of 1,500 mL and an output of 1,600 mL in 24 hours.
A client who has Graves' disease with a heart rate of 100/min and reports tremors.
A client who has had a left-sided stroke reports a severe headache and is manifesting confusion.
The Correct Answer is D
Choice A reason:
While a blood glucose level of 120 mg/dL is slightly above the normal range, it is not typically considered an emergency for a client with type 2 diabetes mellitus. This client would require monitoring and potential adjustment of their diabetes management plan, but it does not necessitate immediate assessment.
Choice B reason:
For a client with diabetes insipidus, an intake of 1,500 mL and an output of 1,600 mL in 24 hours is within expected parameters, considering the condition's characteristic polyuria and polydipsia. This client would need ongoing monitoring to maintain fluid balance but is not the highest priority for immediate assessment.
Choice C reason:
A heart rate of 100/min and tremors in a client with Graves' disease could indicate that their condition is not well-controlled. However, these symptoms are not as acutely concerning as those of a stroke and would be addressed after more urgent needs are met.
Choice D reason:
A client who has had a left-sided stroke and reports a severe headache and confusion is exhibiting signs of a possible acute neurological change or complication, such as increased intracranial pressure or hemorrhage. This client requires immediate assessment and intervention due to the potential for rapid deterioration and life-threatening complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Applying a foot plate to the bed is not primarily intended to prevent pressure points from developing around the edges of the splint. A foot plate can help in maintaining proper alignment and preventing foot drop, but it does not address the issue of pressure points caused by the splint.
Choice B reason:
Repositioning the client is a key intervention to prevent pressure points. By changing the client's position regularly, the nurse can ensure that no single area is under prolonged pressure, which could lead to skin breakdown and pressure sores. This is particularly important in clients with limited mobility due to skeletal traction.
Choice C reason:
Removing the weights for a few minutes each hour is not a standard practice for preventing pressure points in balanced skeletal traction. The weights are integral to maintaining the necessary pull on the fractured femur, and their removal could disrupt the traction setup and potentially affect fracture healing.
Choice D reason:
Applying lotion to the skin under the edges of the splint is not recommended as it could soften the skin and make it more susceptible to injury. Instead, padding and proper positioning are used to protect the skin from the hard edges of the splint.
Correct Answer is B
Explanation
Choice A reason:
Using an antibiotic ointment is not typically recommended as a preventive measure for skin integrity during radiation therapy. Antibiotic ointments are used to treat bacterial infections, and their use should be directed by a healthcare provider if an infection is present or there is skin breakdown.
Choice B reason:
It is important not to apply heat to the area of irradiation as heat can increase skin irritation and the risk of burns in the treated area. Patients undergoing radiation therapy are advised to avoid heat sources, including heating pads, hot water bottles, and direct sunlight, to prevent further damage to the skin.
Choice C reason:
Lubricating the skin with hypoallergenic lotion can help maintain skin integrity by keeping it moisturized. However, it is crucial to use lotions that are free of metals, alcohol, perfumes, and dyes, as these can react with radiation and cause skin irritation. Lotions should be applied after radiation therapy sessions and not immediately before treatment.
Choice D reason:
The instruction not to wash the area of irradiation is incorrect. It is essential to keep the skin clean to reduce the risk of infection. Patients should gently wash the irradiated area with lukewarm water and mild soap, and pat the area dry with a soft towel. They should avoid scrubbing or using harsh soaps that can irritate the skin.
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