A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
A client who has sinus arrhythmia and is receiving cardiac monitoring.
A client who has a hip fracture and a new onset of tachypnea.
A client who has epidural analgesia and weakness in the lower extremities.
A client who has diabetes mellitus and an HbA1c of 7.2% (less than 7%).
The Correct Answer is B
A. Sinus arrhythmia is a benign condition that does not typically require immediate assessment unless accompanied by other concerning symptoms.
B. Tachypnea in a client with a hip fracture may indicate a potential complication such as pulmonary embolism or respiratory compromise, requiring immediate assessment and intervention.
C. While weakness in the lower extremities in a client with epidural analgesia warrants assessment, it is not as urgent as assessing a client with new-onset tachypnea.
D. An HbA1c level of 7.2% in a client with diabetes mellitus, while slightly above the target range, does not require immediate assessment or intervention unless accompanied by acute symptoms of hyperglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While physical therapy may be involved in ALS care for mobility and activities of daily living, they are not the priority for addressing dysphagia.
B. Occupational therapy may be involved in ALS care for mobility and activities of daily living, they are not the priority for addressing dysphagia.
C. Dysphagia in amyotrophic lateral sclerosis (ALS) requires collaboration with a speech-language pathologist to assess swallowing function, recommend safe
feeding techniques, and possibly provide swallowing therapy. Ensuring adequate nutrition and preventing aspiration are crucial aspects of care for clients with ALS and dysphagia.
D. Consulting a dietitian is important for nutritional support, but ensuring safe swallowing takes precedence.
Correct Answer is ["A","B","D","F","G","I","J"]
Explanation
Yellowing of the eyes could indicate hepatotoxicity, a serious adverse effect associated with some of the anti-tuberculosis medications, particularly rifampin.
Blurred vision could be a sign of optic neuritis, a rare but serious adverse effect associated with ethambutol.
Abdominal pain could indicate hepatitis or hepatotoxicity, which are potential adverse effects of anti-tuberculosis medications like isoniazid and rifampin.
Increased bruising could indicate thrombocytopenia, a serious adverse effect associated with some anti-tuberculosis medications, particularly rifampin.
Increased bleeding tendency could also indicate thrombocytopenia or other hematologic abnormalities.
Red/orange tint to urine could indicate rifampin-induced discoloration of bodily fluids, which is not harmful but can be alarming to patients.
Darkening of urine could also be a result of rifampin-induced discoloration. It's important to differentiate between this harmless side effect and hematuria, which could indicate a more serious issue.
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