A nurse is conducting a Romberg test as part of a patient’s physical assessment. Which of the following methods should the nurse employ?

Choice A rationale

The client’s symptoms of itching, anxiety, a flushed face, and hives after the initiation of a blood transfusion are indicative of an allergic reaction. These symptoms suggest that the client may be having a reaction to the transfused blood, which can occur if the client’s immune system reacts against the blood cells or other components of the transfused blood.

Choice B rationale

While some side effects can occur during a blood transfusion, the symptoms the client is experiencing are not normal side effects of the procedure. Normal side effects might include a slight fever or chills.

Choice C rationale

Although the client is experiencing anxiety, this is likely a symptom of the allergic reaction rather than an indication of an anxiety disorder.

Choice D rationale

Hypersensitivity to the IV gauge material is unlikely to cause the symptoms the client is experiencing. Hypersensitivity reactions to medical device materials are rare and would not typically cause systemic symptoms like itching and hives.

Choice A rationale: Client 1 is admitted with a new diagnosis of rheumatoid arthritis. While this condition can cause discomfort and requires management, it is a chronic condition that does not typically present an immediate threat to the client’s health. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.

Choice B rationale: Client 2 has a history of hyperlipidemia and has been administered Atorvastatin 20 mg PO as prescribed. Hyperlipidemia is a chronic condition that requires ongoing management, but it does not typically present an immediate threat to the client’s health. The fact that the client has been administered their medication as prescribed suggests that their condition is currently being managed effectively. Therefore, while this client will need to be monitored to ensure that their medication continues to be effective, they are not the highest priority at this time.

Choice C rationale: Client 3 is 1 day postoperative and reports pain as 8 on a scale of 0 to 10, even after Morphine 5 mg subcutaneous was administered as prescribed. This indicates that the client’s pain is not well controlled and could be a sign of complications. Therefore, immediate assessment is required. This client should be the nurse’s highest priority.

Choice D rationale: Client 4 is admitted with a new diagnosis of heart failure. Heart failure is a serious condition that can have life- threatening complications. However, the fact that this is a new diagnosis suggests that the client’s condition is not yet severe enough to require immediate intervention. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.

Choice E rationale: Client 5 has a stage 2 pressure injury on the left heel. Pressure injuries can lead to serious complications, including infection and tissue necrosis. However, a stage 2 pressure injury is a relatively minor injury that is unlikely to present an immediate threat to the client’s health. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their pressure injury, they are not the highest priority at this time.

Choice F rationale: Client 6 is admitted with a new diagnosis of diabetes mellitus. Diabetes is a chronic condition that requires ongoing management. However, the fact that this is a new diagnosis suggests that the client’s condition is not yet severe enough to require immediate intervention. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.