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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason:
Annular lesions are ring-shaped with a clear center, which does not describe a lesion with a wavy border. This term is typically used for lesions like ringworm, which present as circular rashes with normal skin in the center.

Choice B reason:
Circinate lesions are also circular but are not characterized by a wavy border. They are similar to annular lesions but often have a more rounded edge and are associated with conditions like psoriasis.

Choice C reason:
Coalesced lesions refer to multiple lesions that have merged to form a larger one. While they can have irregular borders, 'coalesced' does not specifically describe the wavy nature of the border.

Choice D reason:
Serpiginous lesions have a wavy or snake-like border, which matches the description provided by the nurse. This term is often used for parasitic infections, such as cutaneous larva migrains, which create a trail-like pattern on the skin.

A. Headache, restlessness B. Decreased blood pressure, rapid pulse C. Muscle cramps, chest heaviness D. Pain and tingling at the access site

Correct Answer is A

Explanation

Choice A reason:
Phenytoin is an antiepileptic drug that can be used to treat and prevent seizures. Headache and restlessness could be signs of neurological irritation or an impending seizure, which phenytoin can help to manage. It is important to monitor the client's neurological status closely following hemodialysis, as changes in electrolyte balance can affect neuronal activity.

Choice B reason:
Decreased blood pressure and rapid pulse are not typical indications for administering phenytoin. These symptoms could indicate hypovolemia or other cardiovascular issues that may occur after hemodialysis, which would require different interventions.

Choice C reason:
Muscle cramps and chest heaviness are not indications for phenytoin administration. Muscle cramps can be a common side effect of hemodialysis due to electrolyte shifts, and chest heaviness may indicate cardiovascular strain or other complications.

Choice D reason:
Pain and tingling at the access site are typically related to the vascular access itself and are not treated with phenytoin. These symptoms may require assessment for potential complications such as infection or thrombosis at the access site.

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A nurse has received a report on a group of clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a new skin lesion that has a wavy border. The nurse should document the lesion using which of the following descriptions?

Correct Answer is D

Explanation

A nurse is caring for a client immediately following a hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN dose of phenytoin?

Correct Answer is A

Explanation

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