A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?

Urinary hesitancy

Dysphagia

Swollen gums

Pruritus

Answer and Explanation

The Correct Answer is B

Choice A Reason: This choice is incorrect because urinary hesitancy is not the priority finding for the nurse to address.

Urinary hesitancy is a difficulty or delay in starting or maintaining a urine stream. It may be caused by various factors such as prostate enlargement, urinary tract infection, medication side eﬀects, or psychological issues. It may cause discomfort, pain, or urinary retention, but it does not pose an immediate threat to the client's life.

Choice B Reason: This choice is correct because dysphagia is the priority finding for the nurse to address. Dysphagia is a difficulty or inability to swallow food or liquids. It may be caused by various factors such as stroke, Parkinson's disease, dementia, esophageal cancer, or oral infections. It may cause malnutrition, dehydration, aspiration, or choking, which can lead to serious complications such as pneumonia, sepsis, or death. Therefore, the nurse should assess the client's swallowing function and provide appropriate interventions such as modifying the diet texture, using thickening agents, or teaching swallowing techniques.

Choice C Reason: This choice is incorrect because swollen gums are not the priority finding for the nurse to address. Swollen gums are an inﬂammation or enlargement of the gingival tissue that surrounds the teeth. They may be caused by various factors such as poor oral hygiene, gum disease, vitamin deficiency, medication side eﬀects, or hormonal changes. They may cause bleeding, pain, or infection, but they do not pose an immediate threat to the client's life.

Choice D Reason: This choice is incorrect because pruritus is not the priority finding for the nurse to address. Pruritus is a sensation of itching that aﬀects the skin. It may be caused by various factors such as dry skin, allergies, eczema, psoriasis, liver disease, or kidney disease. It may cause discomfort, scratching, or skin damage, but it does not pose an immediate threat to the client's life.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect because a client who is post-CABG and has high cholesterol is not in immediate danger, as atorvastatin is a long-term medication that lowers cholesterol and prevents cardiovascular complications.

Choice B Reason: This is incorrect because a client who has pneumonia and a slightly elevated WBC count is not in immediate danger, as piperacillin is an antibiotic that treats bacterial infections.

Choice C Reason: This is correct because a client who has renal failure and a high serum potassium level is in immediate danger, as sodium polystyrene sulfonate is an emergency medication that lowers potassium and prevents cardiac arrhythmias.

Choice D Reason: This is incorrect because a client who has anemia and a mild hemoglobin deficiency is not in immediate danger, as epoetin alfa is a long-term medication that stimulates red blood cell production and improves oxygen delivery.

A. Warm, ﬂushed skin B. Hyperactive deep tendon reﬂexes C. Bounding peripheral pulses D. Widened QRS complexes

Correct Answer is D

Explanation

Choice A Reason: This choice is incorrect because warm, ﬂushed skin is not a sign of respiratory acidosis. Warm, ﬂushed skin may indicate fever, infection, inﬂammation, or allergic reaction, but it does not reﬂect the acid-base imbalance in the blood.

Choice B Reason: This choice is incorrect because hyperactive deep tendon reﬂexes are not a sign of respiratory acidosis. Hyperactive deep tendon reﬂexes may indicate hypocalcemia, hyperthyroidism, or spinal cord injury, but they do not reﬂect the carbon dioxide level in the blood.

Choice C Reason: This choice is incorrect because bounding peripheral pulses are not a sign of respiratory acidosis. Bounding peripheral pulses may indicate increased cardiac output, anxiety, or hyperthyroidism, but they do not reﬂect the pH level in the blood.

Choice D Reason: This choice is correct because widened QRS complexes are a sign of respiratory acidosis. QRS complexes are the segments on an electrocardiogram (ECG) that represent the depolarization of the ventricles. A normal QRS complex duration is 0.06 to 0.10 seconds, and a widened QRS complex duration is more than 0.12 seconds. A widened QRS complex may indicate hyperkalemia, which is a common complication of kidney failure and respiratory acidosis. Hyperkalemia is a condition in which the serum potassium level is higher than normal (more than 5 mEq/L). It may cause cardiac arrhythmias, muscle weakness, or paralysis.

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A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?

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Here is the edited text: A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?