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","B","C","D","E"]
Explanation
Choice A Rationale: Forgetting names and faces, especially when previously introduced, can be a sign of memory impairment, which is common in Alzheimer's disease. Choice B Rationale: Neglecting bills and financial responsibilities is a sign of impaired executive function, which can occur in Alzheimer's disease.
Choice C Rationale: Mentioning excitement about starting a new job after retirement is a typical sign of Alzheimer's disease.
Choice D Rationale: Repeatedly forgetting that one has already read the newspaper and reading it again can be a sign of short-term memory loss, a characteristic of Alzheimer's disease.
Choice E Rationale: Placing car keys in unusual places and misplacing items like shoes in unexpected locations can be signs of disorientation and memory problems, which are common in Alzheimer's disease.
Correct Answer is C
Explanation
Choice A Rationale: Applying a vest restraint should not be the first action and should only be considered as a last resort after other alternatives have been explored.
Choice B Rationale: Placing the client in bed with two side rails raised may restrict the client's mobility and is not the first choice for managing agitation.
Choice C Rationale: Placing a seat alarm in the client's chair is the first action to take because it allows the nurse to monitor the client's movements and respond promptly to any attempts to get out of the chair while ensuring safety.
Choice D Rationale: Administering lorazepam should not be the first action and should only be considered after non-pharmacological interventions have been attempted
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