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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Drainage of clear fluid from the ears is not an expected finding for a client who has an epidural hematoma, but rather a sign of a basilar skull fracture, which is a different type of head injury. The clear fluid is cerebrospinal fluid (CSF), which leaks from the brain through the fractured skull.
Choice B: Alternating periods of alertness and unconsciousness is an expected finding for a client who has an epidural hematoma, because it indicates a rapid increase in intracranial pressure (ICP) due to bleeding between the dura mater and the skull. The client may have a brief loss of consciousness at the time of injury, followed by a lucid interval, and then a rapid deterioration of mental status.
Choice C: Narrowing pulse pressure is not an expected finding for a client who has an epidural hematoma, but rather a sign of increased ICP due to any cause. Pulse pressure is the difference between systolic and diastolic blood pressure. As ICP rises, it compresses the brainstem and causes bradycardia and hypertension, resulting in a decreased pulse pressure.
Choice D: Extensive bruising in the mastoid area is not an expected finding for a client who has an epidural hematoma, but rather a sign of a basilar skull fracture, which is a different type of head injury. The bruising is also known as Batle's sign, and it occurs due to blood pooling behind the ear.
Correct Answer is C
Explanation
Choice A: Contacting the provider for further orders is not necessary, because the client has type AB blood, which is compatible with any other blood type. The client can receive type B blood without any adverse reactions.
Choice B: Notifying the blood bank of the discrepancy is not required, because there is no discrepancy. The blood bank sent the correct type of blood for the client, according to their blood type.
Choice C: Administering the blood as ordered is the correct action, because type B blood is compatible with type AB blood. The client will not have any transfusion reactions or complications from receiving this type of blood.
Choice D: Completing an incident report is not appropriate, because there is no incident. The nurse did not make any error or mistake in administering the blood to the client. There is no need to document or report anything unusual.
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