A nurse is caring for four clients. Which of the following 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 to 10

A client who is 3 days postoperative following abdominal surgery and is ready for discharge

Answer and Explanation

The Correct Answer is A

a. A client with Alzheimer's disease and bacterial pneumonia with newly onset restlessness may be experiencing delirium, which could indicate a worsening of their pneumonia or another underlying issue. Delirium can be a sign of a serious medical condition and requires immediate assessment to determine the cause and provide appropriate intervention.

b. While a fasting blood glucose level of 200mg/dL in a newly admitted client with diabetes mellitus is high and requires attention, it is not as urgent as assessing a client with newly onset restlessness, as described in option a.

c. A client who is 24 hours postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10 requires assessment and pain management, but it is not as urgent as assessing the client with newly onset restlessness.

d. A client who is 3 days postoperative following abdominal surgery and is ready for discharge may require routine assessment and preparation for discharge, but it is not as urgent as assessing the client with newly onset restlessness.

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Correct Answer is C

Explanation

a. Ask the client if she would like a sedative to help her relax:

Offering a sedative may not address the underlying reasons for the client's desire to leave. Moreover, administering a sedative without addressing the client's concerns or obtaining informed consent would not be appropriate.

b. Inform the client that she cannot leave without a discharge prescription from the provider:

While informing the client of the discharge process is important, presenting this information as a restriction may not be the most therapeutic approach. Additionally, in many healthcare settings, patients have the legal right to leave against medical advice, so presenting it as a requirement may not be accurate.

c. Have the client sign the Against Medical Advice form:

When a client decides to leave against medical advice, it is standard practice to have them sign an Against Medical Advice (AMA) form. This form documents the client's decision and acknowledges that they are leaving the hospital against the advice of the healthcare provider.

d. Assign a security officer to the client's room until the provider can speak with the client:

Assigning a security officer may be appropriate in situations where there are concerns for the safety of the client or others, such as if the client is agitated or threatening harm. However, in this scenario, the client has expressed a desire to leave, and assigning a security officer may escalate the situation unnecessarily.

A. Continue the medication dosages that relieve the client’s pain B. Contact the provider about replacing the opioid with an NSAID C. Administer the benzodiazepine but withhold the opioid D. Withhold the benzodiazepine but continue the opioid

Correct Answer is A

Explanation

A. Continue the medication dosages that relieve the client’s pain:
Opioids and benzodiazepines are commonly used for pain and anxiety management in terminally ill patients. Somnolence is an expected side effect and does not necessarily warrant withholding medication unless the client shows signs of respiratory depression.

B. Contact the provider about replacing the opioid with an NSAID: NSAIDs are not sufficient for severe pain in terminal illness. Opioids are the gold standard for palliative pain management, and switching to an NSAID would likely lead to uncontrolled pain and unnecessary suffering.

C. Administer the benzodiazepine but withhold the opioid: This would leave the client in severe pain, which is unethical in hospice care. Pain relief should not be withheld solely due to sedation.

D. Withhold the benzodiazepine but continue the opioid: Benzodiazepines are often used to relieve anxiety, dyspnea, and agitation in end-of-life care. Withholding it could cause increased distress for the client. Instead of discontinuing the medication, the nurse should monitor for respiratory depression and adjust doses only if necessary.

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A nurse is caring for four clients. Which of the following should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been admitted and diagnosed with type 1 diabetes mellitus. The client tells the nurse she has decided to go home. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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