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 postoperative and reports intermittent nausea
A client whose blood pressure is 160/90 mm Hg and reports a headache
A client who is scheduled for surgery in 2 hr
A client who is postoperative and has a Jackson-Pratt drain
The Correct Answer is B
Hypertensive crisis is a severe increase in blood pressure that can lead to organ damage or other complications. Prompt assessment and intervention are necessary to prevent further escalation of blood pressure and potential complications.
While all the clients mentioned require attention, the client with elevated blood pressure and a headache poses a higher immediate risk. The nurse should assess the client's blood pressure, evaluate for signs of target organ damage, and initiate appropriate interventions, which may include administering antihypertensive medications as prescribed and monitoring closely for any changes in the client's condition.
The client who is postoperative and reports intermittent nausea can be assessed and managed after addressing the client with the elevated blood pressure and headache.
The client scheduled for surgery in 2 hours can be addressed according to the scheduled timeline.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
- "Your health care surrogate will make decisions on your behalf if you are unable": This statement is correct. A health care surrogate, also known as a health care proxy or durable power of attorney for health care, is an individual designated by the client to make medical decisions on their behalf if they become unable to make decisions for themselves. It is important for the client to choose someone they trust and who understands their values and wishes.
- "You will need an attorney to appoint a health care surrogate": This statement is not necessarily true. While involving an attorney can be helpful, it is not always required to appoint a health care surrogate. In many jurisdictions, a legally valid health care surrogate designation can be made through a simple document or form provided by the hospital or a local government office. It is important to check the specific legal requirements in the client's jurisdiction.
- "You should appoint a family member as your health care surrogate": This statement is a subjective recommendation and may not be applicable to all individuals. The decision of whom to appoint as a health care surrogate should be based on the client's personal preferences and the individual's ability to make informed decisions according to the client's wishes. While a family member is often chosen, it is not a requirement, and the client may choose a close friend, partner, or anyone else they trust to fulfill this role.
- "Once you have completed a living will, it cannot be changed": This statement is incorrect. A living will, which is a type of advanced directive, can be changed or revoked at any time by the client as long as they are competent to do so. It is important for the client to review and update their living will periodically to ensure that it reflects their current wishes regarding medical care and treatment.
Correct Answer is A
Explanation
Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to vaginal bleeding. The bleeding is typically painless and bright red in color. This is an important finding that should be assessed and monitored closely.
A rigid abdomen is not a characteristic finding of placenta previa. It could be a sign of another condition such as placental abruption or uterine rupture, which are separate complications. Fetal movement is not directly related to placenta previa. It is a normal finding and can vary depending on the gestational age and individual fetal patterns.
Placenta previa is not typically associated with persistent uterine contractions. However, it is important to monitor for any signs of preterm labor or other complications that could cause uterine contractions.
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