A nurse is performing change of shift assessments for four clients. Which of the following findings should the nurse prioritize?
A client who has gastroenteritis and is lethargic and confused
A client who has cystic fibrosis, has a thick, productive cough, and reports thirst
A client who has sickle cell anemia and reports pain 15 minutes after receiving oral analgesic
A client who has diabetes mellitus and has a morning fasting capillary glucose of 185 mg/dL
The Correct Answer is A
A.
A. Gastroenteritis can lead to dehydration and electrolyte imbalances, which can cause lethargy and confusion. This indicates a potentially serious condition requiring immediate attention.
B. While cystic fibrosis requires management, the symptoms described (thick, productive cough and thirst) are not immediately life-threatening.
C. Sickle cell anemia pain is significant but may not require immediate intervention if the client has just received analgesia and is being monitored.
D. While a morning fasting capillary glucose of 185 mg/dL is elevated in a client with diabetes mellitus, it does not require immediate intervention unless accompanied by symptoms of hyperglycemia such as confusion or lethargy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While a blood pressure of 156/90 mm Hg may be elevated, it is not necessarily an indication to withhold propranolol, which is commonly used to treat hypertension.
B. A pulse rate of 54/min suggests bradycardia, which is a potential side effect of propranolol and may warrant withholding the medication.
C. A potassium level of 5.2 mEq/L is within the normal range (3.5-5.0 mEq/L) and is not typically a reason to withhold propranolol.
D. A sodium level of 130 mEq/L is within the normal range (135-145 mEq/L) and is not typically a reason to withhold propranolol.
Correct Answer is C
Explanation
A. Compulsive attention to details: This behavior is more characteristic of obsessive-compulsive personality disorder rather than antisocial personality disorder.
B. Avoids interacting with others: Antisocial personality disorder is characterized by a disregard for and violation of the rights of others, but avoidance of social interaction is not a typical
feature.
C. Uses others for personal gain: This behavior aligns with the manipulative and exploitative tendencies often seen in individuals with antisocial personality disorder.
D. Socially awkward in group situations: While individuals with antisocial personality disorder may have difficulty forming meaningful relationships, they often have superficial charm and can be socially adept, so being socially awkward in group situations is less indicative of this disorder.
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