A nurse on a medical surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?
A client who is scheduled for surgery in 2 hr
A client whose blood pressure is 160/90 mm Hg and reports a headache
A client who is postoperative and reports intermittent nausea
A client who is postoperative and has a Jackson Pratt drain
The Correct Answer is B
A. Incorrect. While a client scheduled for surgery is important, addressing the client with elevated blood pressure and a headache takes priority.
B. Correct. The client with elevated blood pressure and a headache requires immediate assessment, as these symptoms could indicate a hypertensive crisis or other serious complications.
C. Incorrect. While addressing postoperative nausea is important, the client with elevated blood pressure and headache requires more immediate attention.
D. Incorrect. A client with a Jackson Pratt drain may need care and assessment, but a client with elevated blood pressure and a headache has a more urgent need for evaluation.
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Naxlex Comprehensive Predictor Exams
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Explanation
A. Correct. Insomnia, or difficulty falling asleep or staying asleep, is a common manifestation of nicotine withdrawal.
B. Diarrhea is not a typical manifestation of nicotine withdrawal.
C. Weight gain, not weight loss, is more commonly associated with nicotine withdrawal.
D. Diaphoresis (excessive sweating. can be associated with nicotine withdrawal, but insomnia is a more direct withdrawal symptom.
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