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. Speaking directly into one of the client's ears may not effectively improve communication for someone with a hearing impairment, especially if the impairment is bilateral.
B. Rephrasing sentences the client does not understand can help improve comprehension by providing information in a different way.
C. Dropping voice volume at the end of sentences may make it difficult for the client to hear the end of the sentence, especially if they have a hearing impairment.
D. Exaggerating lip movements may not be helpful and can actually make lip-reading more difficult for some individuals.
Correct Answer is A
Explanation
A.
A. Hepatitis C is a contraindication to atorvastatin due to the potential for hepatotoxicity and worsening liver function in individuals with preexisting liver disease.
B. Crohn's disease, peptic ulcer disease, and bronchitis are not contraindications to atorvastatin.
However, caution may be needed in individuals with gastrointestinal conditions due to potential gastrointestinal side effects of the medication.
C. Peptic ulcer disease is not a contraindication to atorvastatin. However, caution may be warranted in individuals with a history of gastrointestinal bleeding or ulcers due to potential gastrointestinal side effects of the medication.
D. Bronchitis is not a contraindication to atorvastatin. Atorvastatin primarily affects cholesterol levels and does not directly interact with bronchitis, a respiratory condition.
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