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A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
- A. Client with surgical hypoparathyroidism and positive Trousseau's sign
- B. Client with Clostridium difficile and acute diarrhea
- C. Client with acute kidney injury and low urine specific gravity
- D. Client with oral cancer and reports a sore on his gums
Correct Answer: A
Rationale: The correct answer is A. A positive Trousseau's sign indicates hypocalcemia, which can lead to life-threatening complications like tetany or laryngospasm, making it the highest priority. Choices B, C, and D, while important, do not pose immediate life-threatening risks compared to the potential complications of severe hypocalcemia seen in a client with surgical hypoparathyroidism and a positive Trousseau's sign.
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A nurse is assessing a client who was brought to the psychiatric emergency services by law enforcement. The client has disorganized, incoherent speech with loose associations and religious content. The nurse should recognize these signs and symptoms as consistent with which of the following?
- A. Alzheimer's disease
- B. Schizophrenia
- C. Substance intoxication
- D. Depression
Correct Answer: B
Rationale: The correct answer is B: Schizophrenia. Disorganized speech, loose associations, and religious delusions are characteristic symptoms of schizophrenia. In this scenario, the client's presentation aligns with positive symptoms of schizophrenia, indicating a severe mental disorder requiring immediate attention. Choice A, Alzheimer's disease, primarily involves cognitive decline and memory impairment, not disorganized speech or religious content. Choice C, Substance intoxication, may present with altered mental status but typically lacks the persistent pattern of symptoms seen in schizophrenia. Choice D, Depression, is associated with a different set of symptoms such as low mood, anhedonia, and changes in appetite or sleep, rather than disorganized speech and loose associations.
A client has a prescription for sertraline to treat depression. Which of the following statements by the client indicates an understanding of the medication treatment plan?
- A. I will start feeling better immediately after starting the medication
- B. I can expect to urinate frequently while on this medication
- C. I understand I may experience difficulty sleeping on this medication
- D. I should decrease my sodium intake while on this medication
Correct Answer: C
Rationale: The correct answer is C. Difficulty sleeping is a common side effect of sertraline, an SSRI used to treat depression. Clients should be educated to expect this, especially during the early stages of treatment. Choice A is incorrect because sertraline may take a few weeks to show its full effect. Choice B is incorrect as increased urination is not a common side effect of sertraline. Choice D is unrelated to the side effects or management of sertraline.
A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?
- A. Feeling flushed and warm
- B. Abdominal fullness
- C. Swollen lips
- D. Metallic taste in the mouth
Correct Answer: C
Rationale: Swollen lips indicate a potential allergic reaction or anaphylaxis to the contrast dye used during the procedure, which requires immediate medical intervention. Abdominal fullness and metallic taste are common side effects of IV urography and can be managed without urgent intervention. Feeling flushed and warm may also be a common reaction during the procedure and does not indicate a life-threatening situation like an allergic reaction.
A client is recovering from an acute myocardial infarction. Which of the following interventions should the nurse include in the plan of care?
- A. Draw a troponin level every four hours
- B. Perform an EKG every 12 hours
- C. Plan for oxygen therapy with a rebreather mask
- D. Obtain a cardiac rehabilitation consult
Correct Answer: D
Rationale: The correct answer is to obtain a cardiac rehabilitation consult. Cardiac rehabilitation is an essential part of the care plan for a client recovering from a myocardial infarction. It helps in improving recovery, enhancing quality of life, and reducing the risk of future cardiac events. Drawing troponin levels and performing EKGs are important for diagnosing and monitoring myocardial infarctions but are not interventions in the post-MI care plan. Oxygen therapy may be necessary based on the client's condition but is not specific to post-MI care.
A nurse is assisting with mass casualty triage following an explosion at a local factory. Which of the following clients should the nurse identify as the priority?
- A. A client who has massive head trauma
- B. A client who has full-thickness burns to the face and trunk
- C. A client with indications of hypovolemic shock
- D. A client with an open fracture of the lower extremity
Correct Answer: C
Rationale: In a mass casualty situation, the nurse should prioritize the client with indications of hypovolemic shock. Hypovolemic shock is an immediate life-threatening condition resulting from severe blood loss, which can lead to organ failure and death. Prompt identification and treatment of hypovolemic shock are crucial to prevent further deterioration. While clients with massive head trauma, full-thickness burns, and open fractures require urgent care, hypovolemic shock takes precedence due to its rapid progression to a critical state.