A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first?

A client who has multiple sclerosis and reports ataxia and vertigo

A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89%

A client who has left-sided paralysis and slurred speech from a prior stroke

A client who has thrombocytopenia and reports a nosebleed

Answer and Explanation

The Correct Answer is D

The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first, as this client has the most urgent problem and is at risk of hemorrhage. Thrombocytopenia is a condition characterized by a low platelet count, which impairs blood clotting and increases bleeding tendencies. The other clients have chronic or stable conditions that require ongoing monitoring and intervention, but are not as urgent as the client with the nosebleed.

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Correct Answer is B

Explanation

Abdominal distension and firmness indicate increased intra-abdominal pressure, which can compromise blood flow to the bowel and cause ischemia, necrosis, or perforation.

The nurse should report this finding to the provider and assess for signs of shock or peritonitis.

A. Deviation of the tongue from midline B. Loss of peripheral vision C. Disequilibrium with movement D. Inability to smell

Correct Answer is C

Explanation

The nurse should expect disequilibrium with movement if the client has impaired function of the vestibulocochlear nerve, as this nerve is responsible for hearing and balance. Deviation of the tongue from midline indicates impairment of the hypoglossal nerve (cranial nerve XII), loss of peripheral vision indicates impairment of the optic nerve (cranial nerve II), and inability to smell indicates impairment of the olfactory nerve (cranial nerve I).

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A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?

Correct Answer is C

Explanation

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