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 A
Explanation
Choice A reason:
Arthralgia, or joint pain, is a common symptom associated with heterotopic ossification (HO), especially when it occurs near joints. The ectopic bone formation can lead to restricted movement and pain during joint movement.
Choice B reason:
Bradycardia, or a slower than normal heart rate, is not directly associated with HO. While spinal cord injuries can affect autonomic control and potentially lead to bradycardia, it is not a symptom specifically linked to the presence of HO.
Choice C reason:
Fecal impaction may occur in patients with spinal cord injuries due to mobility issues and changes in bowel function, but it is not a direct result of HO. HO does not typically affect bowel movements unless the ossification is in a location that mechanically obstructs the bowel.
Choice D reason:
Hypertension, or high blood pressure, is not a symptom commonly associated with HO. While individuals with spinal cord injuries may experience dysregulation of blood pressure, this is not specifically related to HO.
Correct Answer is D
Explanation
Choice A reason:
Monitoring temperature is important postoperatively as it can indicate infection or inflammation. However, it is not the immediate priority following a thyroidectomy. The primary concern post-thyroidectomy is ensuring the airway is not compromised due to swelling or bleeding.
Choice B reason:
Monitoring urination is part of postoperative care to ensure kidney function and that the body is adequately eliminating fluids. While important, it is not the priority in the immediate postoperative period following a thyroidectomy.
Choice C reason:
Pain control is essential for patient comfort and recovery. However, while managing pain is a significant aspect of postoperative care, it is not the most critical priority following a thyroidectomy. The nurse must first ensure that the airway is clear.
Choice D reason:
Airway patency is the priority for monitoring a client post-thyroidectomy. Due to the proximity of the surgery to the trachea, there is a risk of swelling, hematoma, or other complications that could lead to airway obstruction. Ensuring the client has a patent airway is crucial to prevent respiratory distress or compromise.
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