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The nurse has reviewed the Graphic Record  and Diagnostic Results at 1030.

Complete the following sentence by using the lists of options.

The nurse should first address the client's

followed by the client's .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

  • Lung sounds: The client is exhibiting slight inspiratory wheezes, suggesting airway narrowing that could worsen quickly, particularly with a history of asthma. Following the ABC priority framework (Airway, Breathing, Circulation), any compromise in breathing must be assessed and managed first to prevent respiratory decline.
  • Bowel sounds: Although bowel sounds are hyperactive, they do not immediately threaten life or stability. They are typically monitored rather than prioritized unless accompanied by severe gastrointestinal symptoms like obstruction.
  • Heart rate: Tachycardia is present but mild at 104/min and not currently associated with hypotension or hypoxia. While important to monitor, it is a secondary concern after ensuring airway patency and addressing breathing issues.
  • Anxiety: Anxiety may be contributing to elevated heart rate and hyperactive bowel sounds but does not represent an immediate physiological risk. Emotional support is important but should be provided after stabilizing airway and circulation.
  • Vaginal spotting: Vaginal spotting, especially in early pregnancy with abdominal tenderness, raises concern for ectopic pregnancy. After securing the airway, the next concern would be assessing for ongoing or worsening vaginal bleeding, which could signify internal hemorrhage.
  • Hemoglobin: The client's hemoglobin is low-normal (11 g/dL), suggesting mild anemia, possibly from chronic or early bleeding. However, there are no signs of active major blood loss requiring emergent correction, so it would not take immediate precedence over bleeding evaluation.


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Related Questions

Correct Answer is ["A","B","D"]

Explanation

  • "Use sunglasses if your eyes are sensitive to light.": After thyroid surgery, especially if the client has Graves’ disease and associated exophthalmos, the eyes may remain sensitive to light. Wearing sunglasses helps protect the eyes from irritation and prevents further discomfort while healing progresses.
  • "Continue eating foods with protein.": Maintaining adequate protein intake is important for healing after surgery. Protein supports tissue repair, immune function, and recovery, making it an essential part of the client’s postoperative nutrition plan.
  • "Remain on bedrest for 3 to 5 days following discharge.": Prolonged bedrest after thyroid surgery is not recommended. Early ambulation helps prevent complications such as blood clots and promotes recovery. Clients are usually encouraged to resume light activities shortly after surgery.
  • "You need to support your neck when coughing or moving.": After thyroidectomy, supporting the neck when coughing, sneezing, or repositioning helps protect the surgical site, reduces strain on the incision, and minimizes discomfort, promoting safer healing.
  • "You will no longer need to take any medications for your thyroid now that you have had surgery.": This is incorrect because many clients require lifelong thyroid hormone replacement therapy after a thyroidectomy to maintain normal metabolic function, depending on how much thyroid tissue was removed.

Correct Answer is B

Explanation

A: Image A shows a newborn wrapped in a blanket with generalized redness on the face but without distinct blotchy areas or pustules. This appearance is more consistent with normal transitional skin changes such as acrocyanosis or overall mild skin redness after birth. It does not match the appearance of erythema toxicum.

B: Image B shows a close-up of the newborn’s face with visible small red blotchy spots, especially around the cheeks and nose. This matches the classic presentation of erythema toxicum, a benign newborn rash appearing within the first 24 hours. It is characterized by red patches with possible small pustules scattered over the face and body.

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