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A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

A.

Acute pain related to renal calculus.

B.

Impaired renal function related to pain.

C.

Risk for aspiration related to vomiting.

D.

Nutritional deficit related to nausea.

Answer and Explanation

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 D

Explanation

A. While safe sex practices can reduce the risk of STIs, they do not eliminate the risk entirely, especially in cases where partners have multiple sexual partners.

B. Not all STIs are transmitted solely through sexual intercourse; some can be transmitted through other means, making this statement overly simplistic.

C. It's important to note that asymptomatic individuals can still be carriers of STIs, so this statement may give a false sense of security.

D. Teaching the importance of adhering to the medication regimen and ensuring follow-up appointments is critical in managing gonorrhea effectively and preventing complications or reinfection. This approach emphasizes the importance of treatment compliance and ongoing health management.

Correct Answer is B

Explanation

A. Bronze pigmentation is often associated with venous insufficiency rather than arterial compromise.

B. Compromised peripheral arterial circulation can lead to decreased blood flow, resulting in uneven or diminished hair distribution on the lower extremities due to lack of nourishment to hair follicles.

C. Lower leg edema is more commonly associated with venous insufficiency rather than arterial insufficiency.

D. A bounding peripheral pulse indicates increased arterial pressure or volume, which is not consistent with compromised arterial circulation, where pulses are typically weak or absent.

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