The nurse is assessing a client admitted with renal stones. During the admission assessment, what is the priority questions to ask?

Recent travel

Typical diet and fluid intake history

Vaccination records

Last bowel movement

Answer and Explanation

The Correct Answer is B

A. Recent travel: Assessing recent travel history is relevant in understanding potential exposure to certain infections or dietary habits specific to certain regions. However, for a client admitted with renal stones, the immediate focus is on understanding factors related to their condition. While travel history might be a part of the overall assessment, it is not the priority question in this context.

B. Typical diet and fluid intake history: This is the priority question. Understanding the client's typical diet, including the types of foods they consume and their fluid intake habits, is crucial. Certain dietary factors, such as high intake of oxalate-rich foods or insufficient fluid intake, can contribute to the formation of renal stones. Gathering this information helps healthcare providers identify potential dietary factors that might have led to the stones, allowing for tailored dietary recommendations and prevention strategies.

C. Vaccination records: Vaccination records are essential for preventive healthcare, but they are not directly related to the assessment of a client admitted with renal stones. While ensuring clients are up-to-date with vaccinations is important, it is not the immediate concern in the context of renal stones.

D. Last bowel movement: Bowel movements are relevant to overall health and can provide information about gastrointestinal function. However, in the specific context of assessing a client admitted with renal stones, understanding the client's bowel movements is not the primary concern. The focus should be on factors directly related to renal stones, such as diet and fluid intake history, which can inform immediate interventions and prevention strategies.

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Correct Answer is D

Explanation

A. Chronic pain - Chronic pain is a concern for the client, but addressing the underlying issue of ineffective tissue perfusion will help alleviate pain by promoting healing and reducing tissue damage.

B. Impaired skin integrity - Impaired skin integrity is a result of ineffective tissue perfusion. By addressing perfusion issues, skin integrity can be improved as tissues receive adequate oxygen and nutrients for healing.

C. Risk for injury - While clients with arterial insufficiency ulcers are at risk for injury, the immediate concern is addressing the ineffective tissue perfusion to prevent complications related to poor circulation, such as tissue necrosis and infection.

D. Ineffective tissue perfusion- Arterial insufficiency ulcers are caused by inadequate blood flow to the tissues. The priority issue for a client with an arterial insufficiency ulcer is ineffective tissue perfusion. Due to decreased blood flow, tissues do not receive enough oxygen and nutrients, leading to delayed wound healing, tissue damage, and potential complications. Interventions should focus on improving circulation, promoting vasodilation, and enhancing perfusion to facilitate wound healing and prevent further tissue damage.

A. Malignant hypothermia B. Pulmonary embolism C. Acute compartment syndrome D. Fat embolism syndrome

Correct Answer is C

Explanation

A. Malignant hypothermia: This is a rare but life-threatening reaction to certain medications used during anesthesia. It doesn't typically manifest with calf edema.

B. Pulmonary embolism: While pulmonary embolism can occur as a complication in some cases, it is characterized by symptoms like sudden shortness of breath, chest pain, and may not directly cause calf edema.

C. Acute compartment syndrome
Increasing edema in the calf of a client with multiple fractures of the leg is a manifestation of acute compartment syndrome. Acute compartment syndrome occurs when there is increased pressure within a muscle compartment, which can lead to reduced blood flow, nerve damage, and tissue hypoxia. The edema and increased pressure can compress blood vessels, nerves, and muscle tissue within the compartment, resulting in symptoms such as severe pain, edema, and potential vascular compromise.

D. Fat embolism syndrome: This syndrome can occur in clients with long bone fractures, but it is characterized by respiratory and neurologic symptoms, not isolated calf edema.

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The nurse is assessing a client admitted with renal stones. During the admission assessment, what is the priority questions to ask?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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