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. "Take the vital signs on all the patients in the lounge and tell me whether there are problems." This instruction is vague and lacks specific information about what "problems" to look for, which may lead to inconsistent reporting.
B. "Do the morning care first on the patients in 205 and 206 who can't get out of bed." This instruction is clear, but it does not specify important details like the specific type of care expected or additional needs.
C. "Give the patient in 204A a shower after breakfast, and call me to check her feet before you get her dressed." This instruction is specific, clear, and provides a follow-up action (check her feet) which is necessary. It allows the nursing assistant to understand exactly what to do and when.
D. "You take care of all the patients in 205 and 206. Let me know how you're doing and whether you need any help." This instruction lacks specificity and does not outline clear tasks or expectations, which may lead to confusion.
Correct Answer is C
Explanation
A. Bradycardia and constipation are symptoms associated with hypothyroidism, not hyperthyroidism, indicating that the dosage may be too low rather than too high.
B. Muscle cramping and dry, flushed skin are not typical indicators of levothyroxine overdose and may reflect other underlying issues.
C. Palpitations and shortness of breath are symptoms indicative of hyperthyroidism, suggesting that the levothyroxine dosage may be too high, leading to an increased metabolic rate and cardiovascular stress.
D. Lethargy and lack of appetite are more consistent with under-treatment or hypothyroidism rather than an overdose of levothyroxine, which typically stimulates metabolic activity.