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.
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Related Questions
Correct Answer is D
Explanation
a. Instruct the client’s family to contact the insurance provider about the oxygen equipment:
This option involves instructing the client's family to take action by contacting the insurance provider. While it may be helpful for the family to be aware of insurance coverage, it does not directly address the immediate issue of the client needing oxygen upon discharge. Additionally, the family may not have the necessary information or authority to resolve the delivery delay.
b. Send an oxygen tank from the facility home with the client:
This option involves providing the client with an oxygen tank from the facility to ensure they have access to oxygen upon discharge. While it may temporarily address the client's immediate need, it may not be feasible or appropriate for the facility to provide oxygen equipment directly without coordinating with the equipment company and following proper protocols.
c. Contact social services about the delivery of the oxygen equipment:
This option involves contacting social services to seek assistance with resolving the delay in oxygen equipment delivery. Social services may be able to intervene and expedite the delivery process or explore alternative solutions to ensure the client's needs are met. Involving social services can be beneficial in navigating complex discharge issues.
d. Notify the provider about the delayed oxygen tank delivery:
It is important to inform the provider about the delay in oxygen equipment delivery so they can be aware of the situation and make any necessary adjustments to the discharge plan or arrange for alternative solutions. The provider may also assist in expediting the delivery or provide additional instructions for managing the situation.
Correct Answer is B
Explanation
a. Rotavirus: Rotavirus is a common cause of diarrheal illness, especially in infants and young children. While it can cause significant morbidity and mortality, it typically does not require reporting to the state health department unless there is an unusual outbreak or cluster of cases.
b. Pertussis: Pertussis, also known as whooping cough, is a highly contagious bacterial respiratory infection caused by Bordetella pertussis. It can lead to severe coughing fits, especially in infants and young children, and can be life-threatening, particularly in vulnerable populations. Due to its potential for causing outbreaks and serious illness, cases of Pertussis are typically reportable to the state health department for surveillance and control measures.
c. Respiratory syncytial virus (RSV): RSV is a common respiratory virus that can cause mild to severe respiratory illness, particularly in young children, older adults, and individuals with weakened immune systems. While RSV infections can lead to hospitalizations, they are not typically reportable to the state health department unless there is a concern for a widespread outbreak or unusual pattern of cases.
d. Group B streptococcus (GBS) is a bacterium commonly found in the genital tract of adults, and while it can cause serious infections in newborns, it's not typically reportable to the state health department unless there are specific circumstances such as outbreaks or unusual patterns of infection.
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