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 C
Explanation
Choice A reason:
While metabolic syndrome is associated with several health issues, it is not a direct risk factor for hyperthyroidism. Metabolic syndrome typically includes conditions like insulin resistance, hypertension, and dyslipidemia, which are more closely related to diabetes and cardiovascular diseases rather than thyroid function.
Choice B reason:
An iodine deficiency is commonly associated with hypothyroidism, not hyperthyroidism. Iodine is essential for the production of thyroid hormones, and a lack of it can lead to decreased hormone production and an underactive thyroid.
Choice C reason:
Graves' disease is the most common cause of hyperthyroidism. It is an autoimmune disorder where the immune system mistakenly attacks the thyroid gland, causing it to produce too much thyroid hormone. A 35-year-old male with Graves' disease would indeed be at high risk for hyperthyroidism.
Choice D reason:
While a family history of autoimmune disorders can increase the risk of developing autoimmune-related hyperthyroidism, it is not as direct a risk factor as having Graves' disease itself. Autoimmune disorders can have a genetic component, but having a family history does not guarantee the development of hyperthyroidism.
Correct Answer is B
Explanation
Choice A reason:
Squamous cell carcinoma typically presents as a rough, scaly, red patch, open sore, or raised growth with a central depression, often on sun-exposed areas of the body. While it can appear as a lesion that varies in color, it is not commonly associated with a nevus that has increased in size.
Choice B reason:
Malignant melanoma is associated with changes in preexisting nevi, such as an increase in size and variations in color. It often appears as a mole that changes in color, size, or feel and may have irregular edges. The description of the lesion provided by the client is characteristic of malignant melanoma, making this the correct diagnosis.
Choice C reason:
Kaposi's sarcoma is a cancer that forms in the lining of blood and lymph vessels and typically appears as patches of abnormal tissue on the skin or mucous membranes. These lesions are usually red or purple and look similar to bruises¹. They are not typically described as nevi that increase in size or lesions that vary in color.
Choice D reason:
Basal cell carcinoma often appears as a slightly transparent bump on the skin, though it can take other forms. It usually presents as a pearly white or pink bump on white skin, or a brown or black bump on darker skin, and is most often found on sun-exposed areas. It is not typically associated with a nevus that has increased in size or an irregularly shaped lesion that varies in color.
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