A nurse in a long-term care facility has received change-of-shift report about four clients. Which of the following clients should the nurse attend to first?
A client who has heart failure and is incontinent of urine
A client who has COPD and dementia and was agitated during the night shift
A client who had a hip arthroplasty 10 days ago and reports pain with ambulation
A client who had a cerebrovascular accident 6 months ago and reports constipation
The Correct Answer is B
The nurse should atend to the client who has COPD and dementia and was agitated during the night shift first. This client may be experiencing respiratory distress or other complications related to their COPD and requires immediate assessment and intervention.
a) A client who has heart failure and is incontinent of urine requires atention, but their needs are not as urgent as those of the client with COPD and agitation.
c) A client who had a hip arthroplasty 10 days ago and reports pain with ambulation requires atention, but their needs are not as urgent as those of the client with COPD and agitation.
d) A client who had a cerebrovascular accident 6 months ago and reports constipation requires attention, but their needs are not as urgent as those of the client with COPD and agitation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A
Rationale:
A) Serve meals with plastic utensils: Serving meals with plastic utensils is essential to reduce the risk of self-harm. Metal utensils could be used by the client to inflict injury upon themselves, so providing plastic utensils is a necessary safety measure to prevent potential harm.
B) Assign another client to accompany the client to therapy sessions: Assigning another client to accompany the client to therapy sessions is not appropriate as it places an undue burden on another client and may not ensure the safety of the at-risk client. Professional staff should provide supervision and support.
C) Assign the client to a private room: Assigning the client to a private room might increase the risk of self-harm due to reduced supervision. It is generally better to place the client in a more observable setting where staff can frequently monitor their condition.
D) Check on the client every 4 hr: Checking on the client every 4 hours is insufficient for someone who has recently attempted suicide. More frequent monitoring, such as constant or every 15-minute checks, is necessary to ensure the client's safety and provide immediate intervention if needed.
Correct Answer is B
Explanation
Cloudy vision is a symptom of cataracts. Cataracts occur when the lens of the eye becomes cloudy, causing visual disturbances such as cloudy or blurry vision.The other options are not typical symptoms of cataracts.
a) Sudden dimmed vision may be a symptom of other eye conditions.
c) Intermitent flashes of light (option c) may be a symptom of other eye conditions such as retinal detachment.
d) Pain in the eyes (option d) is not a typical symptom of cataracts.
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