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 D
Explanation
Choice A Rationale: Ringing in the ears (tinnitus) is not a common symptom of Bell's Palsy. Bell's Palsy primarily affects facial muscles.
Choice B Rationale: Bilateral pain from the neck upward is not a typical manifestation of Bell's Palsy. Bell's Palsy typically affects one side of the face.
Choice C Rationale: Progressive loss of ability to use all facial muscles is not the usual pattern of Bell's Palsy. It typically presents with sudden unilateral weakness of the face.
Choice D Rationale: Sudden unilateral weakness of the face is a hallmark symptom of Bell's Palsy. This condition often causes weakness or paralysis of the facial muscles on one side of the face, leading to facial drooping.
Correct Answer is D
Explanation
Choice A Rationale: Expressing a reluctance to go out and preferring to stay indoors is not necessarily indicative of effective adaptation.
Choice B Rationale: Preferring a bed bath may be a personal choice rather than a sign of adaptation.
Choice C Rationale: Consuming alcohol daily as a means of pleasure may not necessarily indicate effective adaptation and may raise concerns about potential dependence.
Choice D Rationale: Using modified feeding utensils at every meal and acknowledging improvement despite occasional spills indicates a positive attitude toward adaptation and learning to manage daily activities despite physical limitations.
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