Which of the following clients should be considered a priority for immediate assessment and intervention?
A client who has epidural analgesia and weakness in the lower extremities
A client who has diabetes mellitus and an HbA1c of 7.2% (less than 79%).
A client who has sinus arrhythmia and is receiving cardiac monitoring.
A client who has a hip fracture and a new onset of tachypnea.
The Correct Answer is D
A. A client who has epidural analgesia and weakness in the lower extremities: Lower extremity weakness can be a side effect of epidural analgesia. While it requires monitoring, it is typically not immediately life-threatening unless accompanied by other neurological changes.
B. A client who has diabetes mellitus and an HbA1c of 7.2%: An HbA1c of 7.2% indicates slightly above-target blood glucose control. This is a chronic management concern and does not require immediate intervention.
C. A client who has sinus arrhythmia and is receiving cardiac monitoring: Sinus arrhythmia is often a benign, expected finding, particularly in children or young adults. Continuous monitoring is appropriate, but it is not an emergent concern.
D. A client who has a hip fracture and a new onset of tachypnea: New-onset tachypnea in a client with a hip fracture can indicate a serious complication such as pulmonary embolism or fat embolism syndrome. This requires immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Skin cool to touch: Cool skin is more commonly associated with shock states or severe peripheral vasoconstriction, not with a hypertensive crisis. In hypertensive crisis, the client is more likely to have warm skin due to increased circulation from elevated blood pressure.
B. Jugular vein distention: While jugular vein distention can occur in right-sided heart failure or severe fluid overload, it is not a hallmark manifestation of hypertensive crisis. The acute issue in hypertensive crisis is extreme elevation in blood pressure with end-organ effects.
C. Headache: Severe headache is a common and classic symptom of hypertensive crisis due to sudden, extreme elevations in blood pressure causing increased ICP and cerebral vessel stress. It often signals an urgent need for BP control to prevent complications such as stroke.
D. Weak peripheral pulses: Weak pulses are more often associated with low cardiac output or severe arterial obstruction. In hypertensive crisis, peripheral pulses are typically bounding and strong because of the elevated systemic vascular resistance.
Correct Answer is C
Explanation
A. Assist the family to establish a daily routine: Establishing routines can provide structure, but it is more effective after the nurse has assessed the family’s current functioning and needs following the loss.
B. Refer the family to a grief support group: Referral to support groups is beneficial, but it is not the initial step. Understanding the family’s dynamics and coping capacity should precede external referrals.
C. Determine the roles of individual family members: Assessing each member’s role and function helps the nurse understand how the family is coping and identifies areas of strength and need. This assessment guides appropriate interventions and prioritizes support.
D. Encourage the family to assign specific tasks to individual family members: Assigning tasks is part of restoring structure, but it should follow an assessment of roles and capabilities to ensure tasks are appropriate and achievable.
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