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A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. What is the priority nursing problem for this client?
- A. Disturbed thought processes.
- B. Altered sleep pattern.
- C. Imbalanced nutrition: less than.
- D. Risk for injury.
Correct Answer: D
Rationale: The correct answer is D: Risk for injury. The client's symptoms of disorientation, wandering, decreased appetite, and difficulty sleeping indicate an increased risk for falls, accidents, or getting lost. Ensuring the client's safety and preventing any potential harm is the priority.
A: Disturbed thought processes may contribute to the client's disorientation but do not pose an immediate threat to their safety.
B: Altered sleep pattern is concerning but is secondary to the risk of injury in this scenario.
C: Imbalanced nutrition: less than is important, but the immediate priority is addressing the client's safety due to the risk of injury.
In summary, the priority nursing problem for this client is the risk for injury due to their disorientation and wandering behavior, which could lead to accidents or harm.
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A 45-year-old woman with occasional indigestion has had episodes of chest pain and dysphagia to both solids and liquids. An upper GI series and EGD fail to disclose any structural abnormalities. What is the most appropriate initial therapy?
- A. Sucralfate
- B. Proton pump inhibitor
- C. Prokinetic agent
- D. Benzodiazepine
Correct Answer: B
Rationale: The correct answer is B: Proton pump inhibitor. In this case, the patient's symptoms of chest pain, dysphagia to solids and liquids, and indigestion suggest possible gastroesophageal reflux disease (GERD). A proton pump inhibitor helps reduce gastric acid production, alleviating symptoms and potentially healing any esophageal damage caused by reflux. This is the most appropriate initial therapy as it targets the underlying cause.
A: Sucralfate is a cytoprotective agent that may help with mucosal protection but does not address acid suppression, which is crucial in GERD.
C: Prokinetic agents enhance gastrointestinal motility and are not the first-line treatment for GERD.
D: Benzodiazepines are not indicated for the treatment of GERD and do not address the underlying acid reflux issue.
The nurse is caring for a client with a history of deep vein thrombosis (DVT) who is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?
- A. Platelet count.
- B. Prothrombin time (PT).
- C. Hemoglobin level.
- D. White blood cell count.
Correct Answer: B
Rationale: The correct answer is B: Prothrombin time (PT). Warfarin affects the clotting process by inhibiting vitamin K-dependent clotting factors. Monitoring PT helps assess the effectiveness of warfarin therapy and prevent complications like bleeding. Platelet count (A) is important but not directly affected by warfarin. Hemoglobin level (C) and white blood cell count (D) are not typically affected by warfarin therapy.
A client with a history of deep vein thrombosis (DVT) is receiving warfarin (Coumadin). Which instruction should the nurse provide?
- A. Avoid green leafy vegetables.
- B. Take aspirin for headaches.
- C. Use a soft-bristled toothbrush.
- D. Limit fluid intake to 1 liter per day.
Correct Answer: C
Rationale: The correct answer is C: Use a soft-bristled toothbrush. Patients on warfarin are at risk for bleeding due to its anticoagulant effect. Using a soft-bristled toothbrush helps prevent gum bleeding and injury to the gums, reducing the risk of bleeding complications. Avoiding green leafy vegetables (choice A) is not necessary, as consistent intake is key for warfarin dosing. Taking aspirin (choice B) can increase the risk of bleeding. Limiting fluid intake (choice D) is not indicated in this case.
An 89-year-old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him. What age-related condition is likely to be occurring with this client?
- A. Delirium
- B. Presbyopia
- C. Presbycusis
- D. Cerebral dysfunction
Correct Answer: C
Rationale: The correct answer is C: Presbycusis. This age-related condition refers to gradual hearing loss typically seen in older adults. In this case, the client's complaint of people whispering and mumbling suggests difficulty hearing clearly, which aligns with symptoms of presbycusis. Delirium (choice A) is characterized by acute confusion and disorientation, not specifically related to hearing loss. Presbyopia (choice B) is a condition of aging that affects near vision, not hearing. Cerebral dysfunction (choice D) refers to broader cognitive impairment, not specifically related to hearing loss as in presbycusis. Therefore, choice C is the most likely age-related condition in this scenario.
A client with chronic kidney disease (CKD) is scheduled for hemodialysis. Which pre-dialysis assessment finding should the nurse report to the healthcare provider?
- A. Serum potassium of 5.5 mEq/L.
- B. Blood pressure of 180/90 mm Hg.
- C. Heart rate of 80 beats per minute.
- D. Serum sodium of 140 mEq/L.
Correct Answer: B
Rationale: The correct answer is B: Blood pressure of 180/90 mm Hg. High blood pressure can worsen kidney function and increase the risk of cardiovascular complications during hemodialysis. The nurse should report this finding to the healthcare provider for prompt management.
A: Serum potassium of 5.5 mEq/L is slightly elevated but not an immediate concern before hemodialysis.
C: Heart rate of 80 beats per minute is within normal range and not a priority assessment for pre-dialysis.
D: Serum sodium of 140 mEq/L is within normal limits and does not require immediate attention before hemodialysis.