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 epidural analgesia and weakness in the lower extremities.
A client who has diabetes mellitus and an HbA1c of 6.89%.
A client who has a hip fracture and a new onset of tachypnea.
A client who has sinus arrhythmia and is receiving cardiac monitoring.
The Correct Answer is C
Choice A rationale:
The client with epidural analgesia and weakness in the lower extremities might be experiencing complications related to the epidural, such as epidural hematoma or nerve damage. However, the immediate concern is the client with a hip fracture and new onset of tachypnea. Tachypnea can indicate a pulmonary embolism or worsening respiratory status due to the fracture, both of which require urgent assessment and intervention.
Choice B rationale:
The client with diabetes mellitus and an HbA1c of 6.89% has a well-controlled blood glucose level. This condition does not require immediate attention compared to the client with a hip fracture and tachypnea, who might be experiencing a life-threatening complication.
Choice C rationale:
The client with a hip fracture and new onset of tachypnea is the priority for assessment. Tachypnea can be a sign of respiratory distress, which could indicate a pulmonary embolism or worsening lung function due to the fracture. Timely intervention is crucial to prevent further complications.
Choice D rationale:
The client with sinus arrhythmia and cardiac monitoring is stable and does not require immediate attention compared to the client with a hip fracture and tachypnea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Auditory hallucinations are more commonly associated with conditions like schizophrenia or certain types of psychosis. In bipolar disorder, individuals may experience mood swings between depression and mania, but auditory hallucinations are not a typical symptom during a depressive episode.
Choice B rationale:
Illusions of grandeur involve an exaggerated sense of one's importance, power, knowledge, or identity. This symptom is more commonly associated with manic episodes in bipolar disorder, not depressive episodes.
Choice C rationale:
Rapid speech and moving quickly from one idea to the next are characteristic symptoms of a manic episode in bipolar disorder, not a depressive episode. During depressive episodes, individuals often exhibit symptoms such as low energy, feelings of worthlessness, and difficulty concentrating.
Choice D rationale:
Inability to carry out a simple task is a common symptom of depression. Depressed individuals often struggle with daily activities, lose interest in hobbies, and have difficulty concentrating. This symptom aligns with the depressive episode of bipolar disorder.
Correct Answer is C
No explanation
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