The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?
Bowel incontinence.
Impaired bed mobility.
Fluid volume deficit.
Caregiver role strain.
The Correct Answer is C
Choice A reason: While bowel incontinence is a concern, it does not pose an immediate threat to the client's physiological stability like fluid volume deficit does.
Choice B reason: Impaired bed mobility is important to address for long-term rehabilitation, but it is not the most immediate threat to life.
Choice C reason: Fluid volume deficit, especially due to diarrhea, can lead to dehydration and is a life-threatening condition that requires immediate intervention.
Choice D reason: Caregiver role strain is a significant issue but does not take precedence over the client's immediate physical health needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: An allergy bracelet provides immediate visual notification of the client's allergies to all healthcare personnel, which is crucial for preventing allergic reactions.
Choice B reason: Notifying the dietary department is important, but it does not have the same immediate impact on client safety as an allergy bracelet.
Choice C reason: Sending a list of medication allergies to the pharmacy is a necessary step, but it is secondary to providing immediate identification of the client's allergies.
Choice D reason: Placing a latex-free supply cart outside the room is a proactive measure to prevent exposure to latex, but the first step should be to ensure that the client's allergies are clearly identified for all staff.
Correct Answer is D
Explanation
Choice A reason: While the client's medical history and admission assessment provide valuable information, they do not directly measure the current pain experience.
Choice B reason: Vital signs can indicate pain but are not a definitive measure of pain severity as they can be influenced by other factors.
Choice C reason: The frequency of analgesic administration may suggest the level of pain control but does not measure the current pain intensity experienced by the client.
Choice D reason: Asking the client to describe the intensity of the pain is the most direct and effective way to assess pain severity. Pain is subjective, and the client's self-report is considered the gold standard for pain assessment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.