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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This choice is incorrect because slowing the rate to 50 mL/hr may not be enough to prevent cerebral edema, which is a common complication of head injury. Cerebral edema is a swelling of the brain tissue due to increased fluid accumulation. It can cause increased intracranial pressure (ICP), which can lead to brain damage or death. Therefore, the nurse should limit the fluid intake of the client with head injury to avoid worsening the condition.
Choice B Reason: This choice is incorrect because increasing the rate to 250 mL/hr may cause fluid overload, which can also increase the ICP and worsen the cerebral edema. 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, the nurse should avoid giving too much fluid to the client with head injury.
Choice C Reason: This choice is correct because slowing the rate to 20 mL/hr may help to maintain adequate hydration and electrolyte balance, while preventing fluid overload and cerebral edema. This is a conservative approach that can be used until the client's neurological status and ICP are assessed and monitored.
Choice D Reason: This choice is incorrect because continuing the rate at 125 mL/hr may not be appropriate for the client with head injury, depending on their individual needs and condition. The nurse should adjust the fluid rate according to the client's vital signs, urine output, serum osmolality, and ICP. Therefore, the nurse should not assume that this rate is optimal for the client without further evaluation.
Correct Answer is A
Explanation
The correct answer is a. Respiratory status.
Choice A: Respiratory Status
Reason: After the evacuation of a subdural hematoma, monitoring the respiratory status is crucial. This is because changes in respiratory patterns can indicate increased intracranial pressure (ICP) or brainstem compression, which are life-threatening conditions. Ensuring that the airway is clear and that the patient is breathing adequately is the top priority. Normal respiratory rate for adults is 12-20 breaths per minute.
Choice B: Temperature
Reason: While monitoring temperature is important to detect infections or other complications, it is not the immediate priority in the acute postoperative period following a subdural hematoma evacuation. Fever can indicate infection, but it is less likely to cause immediate life-threatening complications compared to respiratory issues.
Choice C: Intracranial Pressure
Reason: Monitoring intracranial pressure (ICP) is very important in patients with brain injuries. Normal ICP ranges from 5-15 mmHg. However, changes in respiratory status can be an early indicator of increased ICP. Therefore, while ICP monitoring is critical, ensuring the patient’s respiratory status is stable takes precedence.
Choice D: Serum Electrolytes
Reason: Serum electrolytes are important to monitor for overall metabolic stability and to detect imbalances that could affect neurological function. Normal ranges for key electrolytes are: Sodium (135-145 mEq/L), Potassium (3.5-4.5 mEq/L), and Chloride (80-100 mEq/L). However, these are not the immediate priority in the acute phase following surgery compared to respiratory status.
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