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The nurse is admitting a client who reports symptoms of dyspnea. The nurse notes edema of the upper arms, face, and neck. What is the nurse's priority assessment?

A.

Degree of upper body vasculature observed.

B.

Arm circumference and degree of edema.

C.

Blood pressure and heart rate.

D.

Peripheral sensation and movement of upper extremities.

Answer and Explanation

The Correct Answer is C

A. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.  

 

B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.  

 

C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.  

 

D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.


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View Related questions

Correct Answer is A

Explanation

A. A garden salad may contain raw vegetables, which can harbor bacteria and pose a risk of infection for a client with neutropenia, making this the concerning choice.

B. Applesauce is typically safe as it is a processed food that has been cooked, reducing the risk of bacterial contamination.

C. A baked potato is also safe as long as it is properly cooked and handled, which minimizes the risk of foodborne illness.

D. Steamed broccoli is safe because the cooking process eliminates harmful bacteria, making it a better choice for someone with neutropenia.

Correct Answer is D

Explanation

A. Gabapentin is an anticonvulsant commonly used to treat neuropathic pain, including trigeminal neuralgia. It works by stabilizing nerve activity and is appropriate for this condition.

B. Carbamazepine is considered the first-line treatment for trigeminal neuralgia as it decreases nerve impulses, which helps reduce pain. It is a commonly prescribed medication for this condition.

C. Baclofen is a muscle relaxant and can be used in combination with anticonvulsants to treat trigeminal neuralgia by reducing muscle spasms associated with nerve irritation.

D. Oxycodone is an opioid analgesic that treats general pain but is not typically effective for the specific type of neuropathic pain experienced in trigeminal neuralgia. Opioids do not address the underlying nerve activity and are not recommended for long-term management of this condition.

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