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 C

Explanation

Choice A reason:
Bradycardia, or a heart rate that is slower than normal, is not a common finding in anemia. Anemia typically results in a compensatory increase in heart rate, known as tachycardia, to maintain adequate oxygen delivery to tissues.

Choice B reason:
Diarrhea is not a direct symptom of anemia. While it can be a postoperative complication due to various reasons, such as medication side effects or infections, it is not a symptom associated with anemia resulting from excess blood loss.

Choice C reason:
Fatigue is a hallmark symptom of anemia, regardless of the cause. When anemia is due to excess blood loss, the body's oxygen-carrying capacity is diminished due to the reduced number of red blood cells. This leads to fatigue, as tissues and organs receive less oxygen than is needed for optimal function.

Choice D reason:
Hypertension is not typically associated with anemia. In fact, anemia can sometimes lead to hypotension, or low blood pressure, because of the reduced volume of red blood cells in the circulatory system.

A. "I will place my leg under a heat lamp every 3 hours." B. "I will wrap a warm, wet towel around my right calf every 4 hours." C. "I keep a heating pad on the calf of my right leg when I am lying down." D. "I will sit on the side of the tub and soak my right leg two times every day."

Correct Answer is B

Explanation

Choice A reason:
Placing the leg under a heat lamp every 3 hours is not recommended for the treatment of cellulitis. Heat lamps can cause burns and excessive drying of the skin, which may worsen the condition.

Choice B reason:
Wrapping a warm, wet towel around the affected area is a safe and effective way to apply heat therapy for cellulitis. It can help improve blood flow and relieve discomfort without the risk of burns associated with dry heat sources.

Choice C reason:
Using a heating pad directly on the skin, especially when lying down, can increase the risk of burns and is not recommended for treating cellulitis. Heating pads can provide uneven heat and may exacerbate swelling and inflammation.

Choice D reason:
Soaking the leg in water is not typically advised for cellulitis, especially if there are open wounds or breaks in the skin. Immersion in water can introduce new bacteria to the affected area and potentially worsen the infection.

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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 is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has a prescription for heat therapy for the treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is B

Explanation

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