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 A
Explanation
A. Encouraging the use of assistive devices like canes can help improve stability and prevent falls in individuals with multiple sclerosis who may experience balance issues. This statement promotes safety and independence in mobility.
B. While exercise is beneficial for individuals with multiple sclerosis, recommending a rigorous program may not be appropriate initially and could potentially exacerbate symptoms.
C. Hot baths can exacerbate symptoms in individuals with multiple sclerosis due to heat sensitivity, so this advice may not be suitable.
D. Scatter rugs can pose a tripping hazard, especially for individuals with mobility issues, so this statement is incorrect and may increase the risk of falls.
Correct Answer is B
Explanation
A: Facilitating problem-solving skills is typically more relevant during the working phase of the therapeutic relationship, not the orientation phase.
B: During the orientation phase, establishing clear roles and responsibilities helps set expectations and boundaries for the therapeutic relationship.
C: Assisting the client in expressing alternative behaviors is also more relevant during the working phase when exploring and implementing change.
D: Determining previous coping skills is important but typically occurs during the assessment phase, which precedes the orientation phase of the therapeutic relationship.
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