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?
client who has a hip fracture and a new onset of tachypnea
client who has diabetes mellitus and an HbA1c of 6.8%.
A client who has epidural analgesia and weakness in the lower extremities
A client who has sinus arrhythmia and is receiving cardiac monitoring
The Correct Answer is A
The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.
This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention.
Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.
The nurse should assess this client first and notify the provider.
Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention.
The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.
The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A. Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.
Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.
The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.
This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention.
Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.
The nurse should assess this client first and notify the provider.
Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention.
The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.
The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A. Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.
Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. The nurse should compare new prescriptions with the list of medications the client reports. This is part of the medication reconciliation process, which is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten.
Choice B is wrong because the nurse should not encourage the client to make his own list after he returns to his home. The nurse should provide the client with an updated and accurate list of medications before discharge and instruct the client to keep it with him at all times.
Choice C is wrong because the nurse should not include any adverse effects of the medications the client might develop. The nurse should include any known allergies or adverse reactions the client has experienced in the past, but not potential adverse effects that have not occurred.
Choice D is wrong because the nurse should not exclude nutritional supplements from the list of medications the client reports. The nurse should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions in the medication reconciliation process.
Some of these products may interact with prescribed medications or affect laboratory results.
Correct Answer is C
Explanation
The correct answer is choice C: “Do you have thoughts of harming yourself?”.
This is the priority question for the nurse to ask the client because it assesses the client’s risk for suicide, which is a serious and potentially life-threatening complication of conduct disorder. The nurse should use a direct and nonjudgmental approach when asking about suicidal ideation and plan.
Choice A: “How do you get along with your peers at school?” is wrong because it is not the most urgent question to ask the client.
While it is important to assess the client’s social relationships and possible peer rejection, this can be done after addressing the client’s safety and mental status.
Choice B: “Do you have a criminal record?” is wrong because it is not relevant to the client’s current condition and might make the client feel defensive or stigmatized.
The nurse should avoid asking questions that imply blame or judgment and focus on the client’s strengths and coping skills.
Choice D: “How do you manage your behavior?” is wrong because it is not appropriate for the nurse to ask the client in an emergency department setting.
This question might imply that the client is responsible for their conduct disorder, which is a complex and multifactorial mental health condition. The nurse should collaborate with the client and their family to develop a behavior management plan that involves positive reinforcement, limit setting, and consistent consequences.
Normal ranges: According to the DSM-5, conduct disorder is characterized by a persistent pattern of behavior that violates the rights of others or societal norms.
The symptoms of conduct disorder include aggression, deceitfulness, destruction of property, serious rule violations, and lack of remorse.
Conduct disorder can cause significant impairment in social, academic, or occupational functioning. The prevalence of conduct disorder is estimated to be 4% among children and adolescents.
The risk factors for conduct disorder include genetic factors, neurobiological factors, environmental factors, and psychological factors.
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