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 A
Explanation
A. Tenderness upon palpation and generalized erythema indicate skin irritation and possible sunburn, which are signs of overexposure to PUVA treatment. This finding suggests that the client may have received excessive ultraviolet exposure, leading to skin damage.
B. Thick skin plaques topped by silvery white scales are characteristic of psoriasis vulgaris itself, not a sign of overexposure to PUVA.
C. Requiring sunglasses because sunlight hurts the eyes may indicate sensitivity but is not a specific indicator of overexposure to PUVA treatment; it could relate to other issues such as underlying eye conditions.
D. Brown, rough, greasy, wart-like papules on the face are not typically associated with PUVA overexposure but could be related to other skin conditions or lesions.
Correct Answer is D
Explanation
A. While safe sex practices can significantly reduce the risk of STIs, they do not eliminate the risk entirely, especially with multiple partners involved.
B. This statement is misleading; not all STIs are transmitted solely through sexual intercourse, as some can also be transmitted through non-sexual means.
C. It is important to recognize that asymptomatic individuals can still be carriers of STIs; thus, this statement may provide false reassurance.
D. Teaching the client about the importance of following the medication regimen and attending follow-up appointments is critical for effective treatment of gonorrhea and preventing further transmission or complications. This approach prioritizes the client’s health and reinforces the need for responsible sexual practices.