A nurse is preparing to care for a group of clients after receiving change-of-shift report. From which of the following clients should the nurse collect data first?
A client who has benign prostate hyperplasia (BPH) and reports dysuria
A client who has ulcerative colitis and reports diarrhea
A client who has emphysema and reports dyspnea
A client who has esophageal cancer and reports painful swallowing
The Correct Answer is C
Choice A reason: A client who has BPH and reports dysuria is not the highest priority, because dysuria is a common symptom of BPH and does not indicate an acute complication. The nurse should monitor the client's urinary output and provide comfort measures.
Choice B reason: A client who has ulcerative colitis and reports diarrhea is not the highest priority, because diarrhea is a chronic symptom of ulcerative colitis and does not indicate an acute complication. The nurse should assess the client's hydration status and electrolyte levels and administer medications as prescribed.
Choice C reason: A client who has emphysema and reports dyspnea is the highest priority, because dyspnea is a sign of respiratory distress and can indicate an acute exacerbation of emphysema. The nurse should assess the client's oxygen saturation and respiratory rate and administer oxygen therapy as prescribed.
Choice D reason: A client who has esophageal cancer and reports painful swallowing is not the highest priority, because painful swallowing is a common symptom of esophageal cancer and does not indicate an acute complication. The nurse should provide the client with soft or liquid foods and administer analgesics as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is judgmental and discouraging. It implies that the client is not making enough effort and does not acknowledge the possible challenges or barriers that the client may face.
Choice B reason: This statement is accusatory and confrontational. It puts the blame on the client and does not offer any support or guidance.
Choice C reason: This statement is empathetic and supportive. It shows that the nurse is interested in the client's situation and wants to help them identify and overcome any obstacles that may have affected their weight loss.
Choice D reason: This statement is unrealistic and dismissive. It does not address the reasons for the weight gain and does not help the client learn from their experience. It also ignores the emotional impact of the setback.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect finding, because elevated blood pressure is not a sign of hypoparathyroidism, which is a condition that occurs when the parathyroid glands produce insufficient parathyroid hormone (PTH). PTH regulates the calcium and phosphorus levels in the blood and bones. Elevated blood pressure can be a sign of hyperparathyroidism, which is the opposite condition.
Choice B reason: This is the correct finding, because involuntary muscle spasms are a sign of hypoparathyroidism, which causes hypocalcemia, or low blood calcium levels. Hypocalcemia can cause neuromuscular irritability and tetany, which are manifested by muscle spasms, twitching, cramps, or seizures.
Choice C reason: This is an incorrect finding, because cold intolerance is not a sign of hypoparathyroidism, but a sign of hypothyroidism, which is a condition that occurs when the thyroid gland produces insufficient thyroid hormone. Thyroid hormone regulates the metabolism and body temperature. Cold intolerance can also be a sign of Hashimoto's thyroiditis, which is an autoimmune disease that causes inflammation and destruction of the thyroid gland.
Choice D reason: This is an incorrect finding, because weight loss is not a sign of hypoparathyroidism, but a sign of hyperthyroidism, which is a condition that occurs when the thyroid gland produces excessive thyroid hormone. Thyroid hormone increases the metabolism and energy expenditure. Weight loss can also be a sign of Graves' disease, which is an autoimmune disease that causes overstimulation and enlargement of the thyroid gland.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
