A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?
Acute pain related to renal calculus.
Impaired renal function related to pain.
Risk for aspiration related to vomiting.
Nutritional deficit related to nausea.
The Correct Answer is A
A. Acute pain is the most immediate and pressing problem for the client, given the reported severe flank pain. Managing pain effectively is a primary concern in nursing care, particularly for clients with renal calculi.
B. While impaired renal function is a concern with renal calculi, the acute pain takes precedence as it requires immediate intervention to enhance the client's comfort and promote better overall health.
C. The risk for aspiration is a potential issue due to nausea and vomiting; however, addressing the pain is more urgent in this scenario.
D. Nutritional deficit related to nausea is also a valid concern but is secondary to the acute pain management. The client’s immediate comfort and pain relief should be prioritized to facilitate recovery and improve overall well-being.
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Correct Answer is C
Explanation
A. While monitoring blood glucose levels is important for managing diabetes, this instruction alone does not specifically address the goal of lowering blood glucose levels and increasing HDL levels.
B. Monthly appointments with a dietitian can be beneficial but are not as essential as incorporating regular exercise into the client’s lifestyle.
C. Regular exercise is a key component in managing type 2 diabetes, as it helps to lower blood glucose levels and can improve HDL cholesterol. Medical approval ensures that the exercise regimen is safe for the client.
D. Limiting calories on days unable to exercise is not a primary focus for managing diabetes and may not be practical or effective in promoting overall health.
Correct Answer is D
Explanation
A. Throbbing pain can be a common response after a fracture and cast application but does not necessarily indicate an emergency situation.
B. Circumferential edema could suggest complications, but it is not as immediately concerning as the vascular status of the limb.
C. An increased temperature in the lower extremity could indicate inflammation or infection, but it does not require immediate intervention compared to signs of impaired circulation.
D. A pale foot with sluggish capillary refill suggests compromised blood flow, which is a medical emergency requiring immediate assessment and intervention to prevent ischemia or compartment syndrome.