A nurse is prioritizing care for four clients following change-of-shift report. Which of the following clients should the nurse attend to first?
A client who has Alzheimer's disease and requires assistance to the bathroom
A client who has diverticulitis and a temperature of 38.3° C (100.9° F)
A client who has a prescription for a sputum specimen to be obtained before breakfast
A client who sustained a head injury 2 days ago and has a decreased level of consciousness
The Correct Answer is D
A. A client who has Alzheimer's disease and requires assistance to the bathroom: This is important but less urgent compared to the risk of worsening condition in a client with a decreased level of consciousness.
B. A client who has diverticulitis and a temperature of 38.3° C (100.9° F): This is a concern, but it is not as immediately critical as a decreased level of consciousness, which may indicate a more severe underlying issue.
C. A client who has a prescription for a sputum specimen to be obtained before breakfast: While important for diagnostic purposes, this is less urgent compared to a decreased level of consciousness.
D. A client who sustained a head injury 2 days ago and has a decreased level of consciousness: This is correct because a decreased level of consciousness in a client with a recent head injury could indicate a serious complication, such as increased intracranial pressure or worsening of their condition, requiring immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Limit physical activity until bladder continence is achieved: Limiting physical activity is not recommended and can impact overall health. Encouraging regular activity may help improve bladder function and overall well-being.
B. Encourage the client to contract the abdominal muscles when they experience the urge to void: Contracting the abdominal muscles is not typically recommended for managing incontinence. The focus should be on bladder training and strengthening the pelvic floor muscles.
C. Instruct the client to void as soon as they feel the urge: This approach may not support bladder training, which aims to increase the time between voids to improve bladder control.
D. Instruct the client to void at scheduled times throughout the day: This is correct as scheduled voiding helps retrain the bladder, gradually increasing the intervals between voids and improving continence.
Correct Answer is D
Explanation
A. "I should consume fish once per week": While consuming fish is beneficial, particularly fatty fish high in omega-3 fatty acids, this alone is not a comprehensive strategy for preventing hypertension.
B. "With a BMI of 30, I should focus on maintaining my current weight": With a BMI of 30, which is classified as obese, the focus should be on reducing weight rather than maintaining it to help prevent hypertension.
C. "I should exercise for 30 minutes three times per week": The recommended amount of exercise for cardiovascular health is at least 150 minutes of moderate-intensity exercise per week, which is more frequent than three times per week.
D. "I should consume no more than 2,000 milligrams of sodium per day": This is correct as reducing sodium intake to no more than 2,000 milligrams per day is a key strategy for preventing and managing hypertension.
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