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 chronic obstructive pulmonary disease and an oxygen saturation of 89%
A client who has multiple sclerosis and reports ataxia and vertigo
A client who has left-sided paralysis and slurred speech from a prior stroke
A client who has thrombocytopenia and reports a nosebleed
The Correct Answer is A
Choice A Reason:
A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% is correct. The nurse should attend to the client with chronic obstructive pulmonary disease and an oxygen saturation of 89% first. Oxygen saturation levels below 90% indicate significant hypoxemia and potential respiratory distress. The client with COPD is at risk for further worsening of their condition due to inadequate oxygenation. Therefore, addressing this client's low oxygen saturation is a priority to ensure their respiratory status is stabilized.
Choice B Reason:
A client who has multiple sclerosis and reports ataxia and vertigo is incorrect. While these symptoms need assessment and care, they are not indicative of an immediate life-threatening situation.
Choice C Reason:
A client who has left-sided paralysis and slurred speech from a prior stroke is incorrect., While this client requires ongoing care, the immediate concern is lower in priority compared to addressing severe hypoxemia.
Choice D Reason:
A client who has thrombocytopenia and reports a nosebleed is incorrect. Although a nosebleed can be concerning due to thrombocytopenia, it is not as immediately critical as addressing severe hypoxemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
A raised lesion with a rolled border - This description might be more indicative of basal cell carcinoma, a different type of skin cancer.
Choice B Reason:
An irregular lesion with irregular borders. Melanoma is a type of skin cancer that originates from melanocytes, the cells responsible for producing the pigment melanin. One of the key characteristics of melanoma is the presence of an irregularly shaped lesion with irregular borders. Melanomas often have uneven, jagged, or notched edges that distinguish them from benign moles or lesions.
Choice C Reason:
A reddened lesion with dilated blood vessels - This description might be more indicative of a vascular lesion or hemangioma, which is not a melanoma.
Choice D Reason:
A scaly lesion with a crusted appearance - This description might be more indicative of squamous cell carcinoma, another type of skin cancer.
Correct Answer is B
Explanation
"I will tell your provider that you do not want to take this medication." - This response does not address the client's concerns and might lead to a confrontational approach.
Choice B Reason:
"Your provider wouldn't prescribe this medication if it weren't necessary." Response B is the most appropriate and therapeutic response in this situation. It acknowledges the client's concerns while also emphasizing the importance of following the provider's prescription. By reassuring the client that the provider's decision to prescribe the medication is based on their assessment and medical judgment, the nurse promotes trust and encourages the client to comply with the treatment plan.
Choice C Reason:
"Most clients feel better after taking the antibiotic." - While true, this response doesn't directly address the client's specific concern and might not alleviate their doubts.
Choice D Reason:
"If you don't take this medication, you will feel worse." - This response might come across as overly negative and could potentially lead to resistance or defensiveness from the client. It's important to approach the situation with empathy and respect for the client's perspective.
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