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 D

Explanation

Choice A Reason: This choice is incorrect because providing a brightly lit environment may stimulate the client and increase the intracranial pressure. A brightly lit environment is an environment that has a high level of illumination or brightness. It may be used for clients who have depression, seasonal aﬀective disorder, or insomnia, but it does not help to reduce the intracranial pressure.

Choice B Reason: This choice is incorrect because teaching controlled coughing and deep breathing may increase the intrathoracic pressure and increase the intracranial pressure. Controlled coughing and deep breathing are techniques that help to clear the airway and improve lung expansion. They may be used for clients who have respiratory infections, chronic obstructive pulmonary disease, or postoperative complications, but they do not help to reduce the intracranial pressure.

Choice C Reason: This choice is incorrect because encouraging a minimum intake of 2000 mL (67.5 oz) of clear ﬂuids per day may cause ﬂuid overload and increase the intracranial pressure. Fluid overload is a condition in which the body has too much ﬂuid, which can impair the function of the heart, lungs, and kidneys. Therefore, restricting ﬂuid intake and using diuretics may be indicated for clients who have increased intracranial pressure.

Choice D Reason: This choice is correct because elevating the head of the bed 20° may help to improve the venous drainage and decrease the intracranial pressure. As explained above, positioning the client in a semi-Fowler's or high-Fowler's position can facilitate breathing and prevent further complications. However, elevating the head of the bed more than 30° may decrease the cerebral perfusion pressure (CPP), which is the diﬀerence between the mean arterial pressure (MAP) and the intracranial pressure (ICP). A normal CPP range is 70 to 100 mm Hg, and a low CPP (<50 mm Hg) can cause cerebral ischemia, herniation, or death. Therefore, elevating the head of the bed to a moderate angle (20°) may be optimal for clients who have increased ICP.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?

Correct Answer is D

Explanation

A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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