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:
Generalized urticaria, or hives, is not a common side effect of radiation therapy for lung cancer. While skin reactions can occur, they are usually localized to the area being treated. Urticaria might be a sign of an allergic reaction, which would require immediate attention, but it is not typically associated with radiation therapy¹.
Choice B reason:
Xerostomia, or dry mouth, is a common side effect of radiation therapy, especially when the radiation field includes salivary glands. For lung cancer patients, if the radiation field is near the neck or upper chest, it could potentially affect salivary gland function. Monitoring for xerostomia is important because it can lead to difficulties in speaking, eating, and swallowing, and it increases the risk for dental problems².
Choice C reason:
While reviewing laboratory test results for low hemoglobin is an important part of nursing care, it is not specific to radiation therapy for lung cancer. Low hemoglobin could be related to the cancer itself or a side effect of other treatments like chemotherapy. It is important to monitor, but not the primary action related to radiation therapy³.
Choice D reason:
Observing for signs of infection is a general nursing responsibility for all patients, not specific to those receiving radiation therapy for lung cancer. However, if the patient's immune system is compromised due to the cancer or other treatments, vigilance for infection is heightened.
Correct Answer is ["A","D","E"]
Explanation
Choice B reason:
Sleeping on a soft mattress is not recommended for preventing low back pain. A medium-firm mattress often provides better support for the spine. A soft mattress may allow the body to sink in too deeply, causing misalignment of the spine during sleep.
Choice C reason:
Applying heat for 10 minutes every hour is not a standard recommendation for preventing low back pain. While heat therapy can help relax muscles and relieve pain, it is typically advised to apply heat for longer periods, such as 15-20 minutes, and not as frequently as every hour.
Choice D reason:
Sleeping in a side-lying position with flexed knees can help maintain the natural curve of the spine and minimize back strain. This position can also reduce pressure on the back and is often recommended for those with low back pain.
Choice E reason:
Trying padded shoe insoles can help minimize back strain by providing additional support and cushioning for the feet, which can improve alignment and reduce the impact on the back during walking or standing.
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