A nurse is caring for four clients. Which of the following clients should the nurse assess first?
A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness
A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL
A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10
A client who is 3 days postoperative following abdominal surgery and is ready for discharge
The Correct Answer is A
a. The client with Alzheimer's disease and bacterial pneumonia experiencing newly onset restlessness may indicate a change in their condition, such as worsening infection or delirium, which requires immediate assessment and intervention to address their underlying medical needs.
b. While hyperglycemia in a newly admitted client with diabetes mellitus is concerning, it does not typically require immediate assessment unless accompanied by signs of diabetic ketoacidosis or other acute complications.
c. Although the client postoperative from hip fracture reduction reporting a pain level of 7 requires attention, it is not as urgent as assessing the client with newly onset restlessness, which may indicate a more acute issue.
d. The client who is 3 days postoperative and ready for discharge does not require immediate assessment compared to the client with newly onset restlessness, whose condition may be deteriorating.
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Correct Answer is D
Explanation
a. While limited social support is important to address for a successful discharge plan, it may not be as urgent as addressing issues directly related to the client's recovery from surgery.
b. Decreased self-esteem is a significant concern but may not directly impact the client's immediate postoperative recovery and discharge plan.
c. Inadequate food supply is important to address for the client's overall well-being but may not be as urgent as addressing issues directly related to the client's recovery from surgery.
d. Low pain tolerance can significantly affect the client's recovery process and may require immediate attention to ensure adequate pain management postoperatively.
Correct Answer is A
Explanation
- A) Knowing the time the client received his last dose of pain medication is crucial for continuity of care, ensuring that the client receives their next dose on time and pain management is consistent.
- B) Personal beliefs about the client's relationships are not relevant to the medical care and should remain confidential unless it directly impacts the care plan.
- C) While important, the detailed steps for wound care will be included in the client's care plan and are not typically communicated during a change-of-shift report unless there is a change or an issue.
- D) The client's preferred time for bathing is a part of personal care preferences and, while important for client comfort, is not critical information for a change-of-shift report unless it affects immediate care needs.
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