After receiving change-of-shift report, which of the following clients should the nurse collect data from first?
A client who has a history of pancreatitis and reports severe abdominal pain
A client who has heart failure and reports severe dyspnea
A client who is scheduled for abdominal surgery in 1 hr
A postoperative client who has diabetes mellitus and a blood glucose of 280 mg/dL
The Correct Answer is B
A. While severe abdominal pain in a client with a history of pancreatitis requires urgent assessment, severe dyspnea in a client with heart failure may indicate impending respiratory distress, requiring immediate intervention.
B. Severe dyspnea in a client with heart failure is a critical situation that requires immediate assessment and intervention to prevent respiratory compromise or failure.
C. While a client scheduled for surgery may need preparation and assessment, the client with severe dyspnea takes priority due to the potential for respiratory distress.
D. While a high blood glucose level in a postoperative client with diabetes mellitus requires monitoring and intervention, the client with severe dyspnea requires immediate attention due to the potential for respiratory compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Correct. This response provides reassurance and normalizes the client's experience by emphasizing that having a colostomy does not prevent individuals from leading fulfilling lives. B. Incorrect. While peer support can be beneficial, this response does not directly address the client's concerns or provide immediate reassurance.
C. Incorrect. This response may put the client on the spot and make them feel uncomfortable discussing their feelings. It's important to respect the client's privacy and autonomy in disclosing their reasons for not wanting others to see the colostomy bag.
D. Incorrect. Making assumptions about the temporary nature of the colostomy without medical confirmation may not be accurate and can contribute to false hope or disappointment if the client's colostomy is permanent. It's important to provide honest and accurate information while being supportive of the client's emotional needs.
Correct Answer is D
Explanation
A. Children whose parents have college degrees may have more access to resources and support systems, potentially reducing the risk of physical abuse.
B. Children who were born after 38 weeks of gestation do not inherently have an increased risk of physical abuse based solely on gestational age at birth.
C. Children whose parents are married may have more stability in their family environment, potentially reducing the risk of physical abuse.
D. Children who live in crowded homes may experience increased stress and tension, leading to a higher risk of physical abuse due to the potential for conflict and limited space.
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