A nurse is receiving change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?
A client who has cirrhosis and severe pruritus
A client who has a femur fracture and reports numbness of the toes
A client who had a renal biopsy 3 hr ago and has pink-tinged urine
A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge
The Correct Answer is B
Numbness of the toes following a femur fracture can indicate potential nerve compromise or damage, which requires immediate attention. Nerve compression or injury can lead to long-term complications if not addressed promptly. It is important for the nurse to assess the client's neurovascular status, including circulation, sensation, and movement, to determine if there is any compromise to the affected limb.
A client with cirrhosis and severe pruritus can be seen next, as pruritus can significantly affect the client's comfort and quality of life. However, it is not immediately life-threatening.
A client who had a renal biopsy 3 hours ago and has pink-tinged urine should be assessed, but this finding is expected after a renal biopsy. The nurse should ensure that the client is monitored for any signs of bleeding or complications, but it may not require immediate attention unless the bleeding worsens or other concerning symptoms arise.
A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge can be seen last, as long as there are no complications or signs of postoperative issues. The nurse should ensure that the client is stable, comfortable, and meeting the necessary criteria for discharge.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hyperactive bowel sounds are bowel sounds that are louder and more frequent than normal. They may be heard as high-pitched rushing or tinkling sounds that occur irregularly at a rate greater than 5-6 sounds per minute. They are often associated with increased intestinal motility, such as diarrhea, gastroenteritis, or early bowel obstruction.
Option b is incorrect because hyperactive bowel sounds are not typically associated with a paralytic ileus, which is a condition where the bowel stops working and there is a lack of bowel sounds.
Option c is incorrect because hyperactive bowel sounds indicate increased motility, not decreased motility.
Option d is incorrect because soft bowel sounds at a rate of 1/min are considered hypoactive bowel sounds, which can be a sign of decreased intestinal motility, as seen in constipation or postoperative ileus.
Correct Answer is A
Explanation
a. Memory loss that disrupts ADLs
Explanation: Dementia is a condition characterized by a decline in cognitive function that affects a person's ability to perform activities of daily living (ADLs). Memory loss is a common symptom of dementia, particularly in the early stages. The memory loss can disrupt a person's ability to carry out tasks they were previously able to do independently, such as dressing, bathing, and eating. Therefore, option a is the correct answer.
Option b, catatonia, is a condition characterized by a lack of movement or activity, which is not typically associated with dementia.
Option c, illusions, involve a misinterpretation of sensory information and may occur in some forms of dementia but are not a defining feature.
Option d, pressured speech, is a symptom commonly associated with mania or bipolar disorder, but is not typically seen in dementia.
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