The nurse is prioritizing a client's problem list. Which of the following problems should receive the highest priority?
Ineffective Sexuality Pattern
Risk for Social Isolation
Activity Intolerance
Imbalanced Nutrition: less than body requirements
The Correct Answer is D
D. This problem indicates that the client is not receiving adequate nutrition to meet metabolic needs, which can lead to malnutrition and compromised healing. Addressing imbalanced nutrition is crucial for maintaining health and supporting recovery.
A. This problem refers to disturbances in sexual function or satisfaction. While important to address, it is not typically considered a high priority compared to other physiological or safety-related issues unless it B This problem indicates the potential for the client to experience loneliness or social disconnection, which can impact mental and emotional well-being. While addressing social isolation is important for holistic care, it may not be as urgent as issues related to physical health or safety.
C This problem indicates the inability to endure physical activities or exercise due to insufficient physiological or psychological energy. Activity intolerance can be a significant concern post-operatively or in clients with chronic conditions, as it can affect recovery and overall functional ability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. A "thready" pulse is weak and difficult to palpate. It feels like a fine thread or string under the fingertips and suggests poor cardiac output or decreased peripheral perfusion. A thready pulse is palpable but weak, indicating inadequate stroke volume with each heartbeat.
A. Hypovolemic refers to a state of decreased blood volume, which can lead to a weak and rapid pulse due to reduced blood flow through the arteries. However, it does not specifically describe the quality of the pulse that is palpable.
B. Bradycardia refers to a slow heart rate, typically below 60 beats per minute in adults. A bradycardic pulse may be slow but can still be strong or weak depending on the underlying cause. It does not specifically describe the quality of a weak but palpable pulse.
C. "Deficient" is not a commonly used term to describe the quality of a pulse. It does not provide specific information about the palpable nature or strength of the pulse.
Correct Answer is A
Explanation
A. One of the primary reasons for administering IV fluids is to correct imbalances in fluid volume or electrolyte concentrations. Examples include correcting dehydration, restoring electrolyte levels (such as sodium, potassium), and addressing fluid losses due to vomiting, diarrhea, or excessive sweating.
B. IV fluids are typically used to increase intravascular volume rather than decrease it. In conditions such as hypovolemia (low blood volume), IV fluids are administered to restore blood volume and improve circulation.
C. Third spacing refers to the abnormal accumulation of fluid in interstitial spaces, which can occur in conditions like sepsis, burns, or trauma. IV fluids are not typically administered to increase third spacing; rather, treatment aims to redistribute fluids and improve fluid balance.
D. Enteral fluids are fluids administered directly into the gastrointestinal tract (via oral or tube feeding). IV fluids are administered directly into the bloodstream and are used when enteral administration is not feasible or sufficient.
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