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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Contact the case manager to discuss discharge options: This is an appropriate action. The case manager can assist in assessing the client's needs and coordinating appropriate discharge arrangements, such as arranging for home health services or exploring alternative care options.
b. Request another family member assist the client’s partner with care: This may be a helpful action if there is another family member who can provide support. However, it's important to consider the availability and willingness of other family members to take on caregiving responsibilities.
c. Recommend the partner place the client in a long-term care facility: This option may be considered if the partner is unable to continue providing care and there are no other feasible options available. However, it should be discussed with the client and their partner and explored as one of several potential solutions.
d. Ask the provider to delay the client’s discharge home for a few more days: This may be appropriate if there are concerns about the client's safety or if additional time is needed to arrange for alternative care options. However, it's important to address the underlying issues contributing to the partner's inability to provide care and to explore long-term solutions.
Correct Answer is D
Explanation
a. "I am not sure how I will pay for all the therapy I will need":
"I am not sure how I will pay for all the therapy I will need":This statement expresses a concern about financial matters related to medical expenses and therapy costs. It is relevant for social services or a financial counselor, not an occupational therapist.This indicates a need for assistance with financial planning and resources, possibly involving a social worker or a financial advisor, rather than an OT.
b. "I hope I can adjust to using crutches while I am recovering":
"I hope I can adjust to using crutches while I am recovering":This statement reflects a concern with mobility and the use of assistive devices, such as crutches, during recovery. While this is an important aspect of rehabilitation, it is typically within the scope of physical therapy (PT) rather than occupational therapy.Physical therapists specialize in improving mobility, strength, and the proper use of mobility aids. Therefore, this would be more relevant for a PT referral.
c. "I just don’t think I can handle looking at my leg":
This statement indicates emotional distress and difficulty in accepting the physical changes after the amputation. This is an important issue, but it suggests a need for psychological support rather than OT intervention.This would be more appropriate for a referral to a mental health professional or counselor to address emotional and psychological concerns related to body image and adjustment.
d. "I am worried about taking care of my toddler":
This statement highlights a concern about the client's ability to manage daily tasks and care for a dependent (in this case, a toddler) at home after the surgery. Occupational therapists specialize in helping clients adapt to daily living activities and manage home responsibilities effectively despite physical limitations.
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