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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Related Questions
Correct Answer is D
Explanation
a. Continuing both medications may exacerbate the somnolence and difficulty arousing experienced by the client. It's essential to address the adverse effects promptly.
b. NSAIDs are not typically the first choice for severe pain management in terminal illness, especially when opioids are already prescribed. Moreover, replacing the opioid with an NSAID may not adequately address the pain.
c. Administering the benzodiazepine alongside the opioid may further potentiate the sedative effects and worsen the client's condition.
d. This is the most appropriate action. Withholding the benzodiazepine can help mitigate the sedation while continuing the opioid ensures ongoing pain relief for the client's comfort without introducing additional sedating medications.
Correct Answer is D
Explanation
a. A client at 37 weeks gestation with an L/S ratio of 2:1 is likely nearing term and may not require an interdisciplinary care conference solely based on this result.
b. A negative Coombs's titer at 28 weeks gestation does not typically warrant an interdisciplinary care conference.
c. A client at 39 weeks gestation with a negative contraction stress test may not require an interdisciplinary care conference unless there are other concerning factors.
d. A biophysical profile of 6 at 35 weeks gestation suggests potential fetal compromise and warrants further evaluation and discussion among interdisciplinary team members in a care conference.
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