A young adult client involved in a minor motor vehicle collision three weeks ago reports having a headache, blurred vision, vertigo, and nausea. The client's vital signs are within normal limits, and a nutrition history reveals that the client is eating very little because of being concerned about paying for car repairs. Priority nursing care should be based on which nursing problem?

High risk for injury related to increased intracranial pressure.

Alteration in comfort related to motor vehicle collision.

Alteration in nutrition related to poor dietary intake.

Anxiety related to unknown outcome of automobile repairs.

Answer and Explanation

The Correct Answer is A

A.   The client's symptoms of headache, blurred vision, vertigo, and nausea, even without abnormal vital signs, are suggestive of potential neurological complications from a head injury, such as increased intracranial pressure (ICP). This requires immediate attention and evaluation.
B.   While the client is experiencing discomfort, it is secondary to the potential neurological issue.
C.   The client's nutritional status is a concern, but it is not the priority at this time, given the potential neurological implications of the client's symptoms.
D.   While the client's anxiety is understandable, it is not the primary concern given the more immediate health risk.

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Correct Answer is B

Explanation

A. This action is typically used in the treatment of hyperkalemia (high potassium levels), not hypokalemia. The combination of glucose and insulin is used to temporarily drive potassium into cells and lower serum potassium levels. For severe hypokalemia, the priority is to administer potassium replacement therapy rather than attempting to lower potassium levels, as the client needs to correct the deficiency.
B. Severe hypokalemia requires prompt correction to prevent complications. Potassium replacement should be administered according to healthcare provider orders. This may involve oral or intravenous potassium supplements, depending on the severity of the hypokalemia and the client's condition. Informing the healthcare provider is essential for ensuring that appropriate and timely treatment is provided.
C. While increasing potassium intake through diet is important for managing mild cases of hypokalemia, a serum potassium level of 2.5 mEq/L is severe and likely requires immediate medical intervention. Dietary changes alone are insufficient and not timely enough to address such a critical deficiency.
D. Monitoring urinary output is important in managing electrolyte imbalances to assess kidney function and fluid balance, but it is not the primary intervention for severe hypokalemia. The immediate priority is to address the low potassium level through appropriate replacement therapy.

A. Assess the client's oxygen saturation level. B. Determine the client's current glucose level C. Give the client one-half cup of fruit juice. D. Give the client skim milk and crackers.

Correct Answer is B

Explanation

A. While oxygen saturation is important, it's not the priority in this situation. The client's symptoms strongly suggest hypoglycemia.
B. The client's symptoms of diaphoresis, rapid heartbeat, and shakiness are classic signs of hypoglycemia. Therefore, the first action should be to confirm this diagnosis by checking the blood glucose level.
C. Administering glucose before confirming hypoglycemia can be dangerous. If the client is hyperglycemic, giving them sugar will worsen their condition.
D. Providing food without confirming hypoglycemia is not appropriate.

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Naxlex Comprehensive Predictor Exams

The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Correct Answer is B

Explanation

A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose Isophane suspension insulin at 0800. At 1600, the client reports having diaphoresis, rapid heartbeat, and feeling shaky. Which should the nurse do first?

Correct Answer is B

Explanation

A client with chronic venous insufficiency is being discharged from the hospital, and plans to return home. Which client statement indicates an understanding of home care instructions?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

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The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

A client receiving thyroid replacement therapy following a thyroidectomy is seen in the dinic for a 6 weeks postoperative check-up. Which assessment is most important for the nurse to obtain?