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 D
Explanation
A. Splitting behavior, where the client views people and situations as either all good or all bad, is more characteristic of borderline personality disorder rather than histrionic personality disorder.
B. Emotional lability, characterized by rapid shifts in mood, is not a primary feature of histrionic personality disorder.
C. Unexpressive affect, or a lack of emotional expression, is not a typical feature of histrionic personality disorder, which often presents with exaggerated and dramatic emotional displays.
D. Self-centered behavior, including attention-seeking and dramatic behavior to gain approval or admiration from others, is a hallmark feature of histrionic personality disorder.
Correct Answer is C
Explanation
A. Absence seizures typically last only a few seconds, not as long as 30 to 60 seconds, so this statement is incorrect.
B. Absence seizures typically occur without warning or aura, so this statement is incorrect.
C. Absence seizures often manifest as brief episodes of staring or blank expression, which can be mistaken for daydreaming or inattention. Educating parents about this characteristic helps them recognize and appropriately respond to absence seizures in their child.
D. Absence seizures have a sudden onset and offset without warning, so this statement is incorrect.
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