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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Correct. This response acknowledges the client's feelings and demonstrates empathy. It opens the door for further discussion and exploration of the client's beliefs without immediately challenging them.
B. Incorrect. Directly contradicting the client's beliefs may cause resistance and increase their distress. It's important to approach the situation with sensitivity and understanding.
C. Incorrect. While asking for clarification is a valid approach, it may not be the most appropriate initial response. It's important to establish trust and rapport with the client before delving into their delusional beliefs.
D. Incorrect. Asking "why" s may put the client on the defensive and may not lead to a productive conversation about their beliefs. It's better to approach the situation with empathy and openness before exploring the client's perspective.

A. Elevated blood pressure B. Bounding pulse C. Fruity breath odor D. Clammy skin

Correct Answer is C

Explanation

A. Elevated blood pressure is not a specific finding associated with diabetic ketoacidosis (DKA..
B. Bounding pulse might be present due to dehydration in DKA, but it's not a defining characteristic.
C. Correct. Fruity breath odor (often described as "fruity" or "acetone-like". is a characteristic sign of DKA due to the presence of ketones in the breath?
D. Clammy skin is not a specific finding associated with DKA.

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A nurse on a medical surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?

Nursing Test Bank

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