After receiving change-of-shift report for clients on the memory unit, which patient will the nurse see first?
A Patient who developed a new cough after eating breakfast
B Patient who is refusing to take the prescribed medications.
C Patient who has not had a bowel movement for 5 days.
D Patient who has a stage Il pressure ulcer on the coccyx
The Correct Answer is A
Choice A Rationale: The patient who developed a new cough after eating breakfast should be seen first. This sudden change in respiratory status during or after eating suggests a potential risk of aspiration, which requires immediate assessment and intervention to prevent respiratory distress or pneumonia.
Choice B Rationale: Medication refusal, while important, is not an immediate life threatening issue compared to a new cough with the potential for aspiration.
Choice C Rationale: Although constipation can be uncomfortable, it is not an acute priority compared to a new cough that may indicate a respiratory problem.
Choice D Rationale: A stage II pressure ulcer on the coccyx, while concerning, is not an immediate priority over a potential respiratory issue that requires urgent attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Rationale: "You sound overwhelmed, can you tell me more?" is an empathetic response that encourages the caregiver to express their feelings and concerns. It opens the door for effective communication and understanding.
Choice B Rationale: "It will take time, but lots of people do it" may be true, but it does not directly address the caregiver's emotional state or offer support.
Choice C Rationale: "What do you think will be the hardest thing to handle?" is a probing question that can help identify specific concerns, but it may not be the most appropriate initial response.
Choice D Rationale: "The entire healthcare team will manage most of the disease process" does not acknowledge the caregiver's emotions and concerns and may not provide the needed support.
Correct Answer is A
Explanation
Choice A Rationale: The client receiving an influenza vaccine 4 weeks ago is relevant because Guillain-Barre syndrome can sometimes be triggered by infections or vaccinations, including influenza vaccines.
Choice B Rationale: The client's hobby of golfing is not directly related to the described symptoms.
Choice C Rationale: Canning jams and preserves is not directly related to the described symptoms.
Choice D Rationale: A history of diabetes, while important for the client's overall health, may not be directly related to the current manifestations.
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