A nurse is caring for a client whose partner died 6 months ago. Which of the following findings is the nurse's priority?

The client states that he is unable to eat more than once a day.

The client frequently recalls negative experiences that occurred during his marriage.

The client relates that he is angry that the provider did not save his partner's life.

The client says he feels guilty about not spending more time with his partner.

Answer and Explanation

The Correct Answer is A

The nurse's priority is to address the client's physical needs, such as nutrition and hydration, which are essential for survival and recovery. The client who is unable to eat more than once a day is at risk for malnutrition, dehydration, and electrolyte imbalance, which can lead to serious complications. The other findings indicate emotional distress and grief, which are also important to address, but not as urgent as the client's physical health.

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Correct Answer is B

Explanation

A: Giving the client atropine 30 min before the procedure is a task that requires professional nursing knowledge and skill to assess the medication's necessity and potential effects, thus it cannot be delegated to an assistive personnel.
B: Assisting with ambulation is a task that can be safely delegated to an assistive personnel, as it does not require the professional judgment or skill of a nurse. The assistive personnel can help maintain the client's safety while walking after the procedure.
C: Witnessing a client's signature on the consent for the procedure is a legal responsibility and requires an understanding of the procedure's risks and benefits, which is beyond the scope of assistive personnel's responsibilities.
D: Checking the client's condition after the procedure involves assessment and interpretation of clinical data, which are responsibilities of the nurse and cannot be delegated to an assistive personnel.

A. Lanugo covering the body B. +2 edema of the lower extremities C. BUN 21 mg/dL D. Blood pH 7.60

Correct Answer is D

Explanation

A blood pH of 7.60 indicates alkalosis, which is a life-threatening condition that can result from vomiting, laxative abuse, or diuretic use in clients who have anorexia nervosa. Alkalosis can cause cardiac arrhythmias, seizures, coma, and death if not corrected promptly. The nurse should notify the provider and prepare to administer IV fluids and electrolytes as ordered. The other findings are also concerning, but they are not as urgent as alkalosis.

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A nurse is caring for a client whose partner died 6 months ago. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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