The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority?

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Question 1 of 5

The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority?

Correct Answer: A

Rationale: Among four diagnoses, chest pain related to pneumonia takes highest priority because it addresses a physiologic need breathing and circulation per Maslow's hierarchy. Pain and potential respiratory compromise threaten survival, requiring immediate intervention like medication or oxygen. Self-care deficits, family process risks, and self-esteem issues, while important, are less urgent, impacting higher-level needs like independence or esteem. Prioritizing chest pain ensures the client's airway and oxygenation are stabilized, preventing deterioration, a fundamental principle in acute care nursing.

Question 2 of 5

While listening to a client's lung sounds, you hear something that you believe is not normal, and you note that it is a continuous sound. You will chart this as which of the following findings?

Correct Answer: C

Rationale: Continuous abnormal lung sounds are charted as adventitious, encompassing wheezes or rubs, unlike intermittent crackles or rales. Pleural rub is specific. Nurses document this for respiratory evaluation.

Question 3 of 5

Which one of the following four clients is most likely to tolerate pain best?

Correct Answer: C

Rationale: An athlete undergoing knee surgery likely tolerates pain best, motivated by career goals, unlike chronic arthritis, cancer grief, or migraines. Nurses consider this in pain management.

Question 4 of 5

Which psychological effect is commonly observed in patients experiencing immobility?

Correct Answer: D

Rationale: Immobility often increases anxiety and depression risk, as patients face mobility loss, dependence, and isolation, fostering psychological distress. Motivation and independence typically wane with restricted activity, while depression risk rises, not falls, due to these constraints. Nurses address this through emotional support and engagement, understanding that mental health declines when physical freedom is curtailed. This effect highlights the need for holistic care, blending physical interventions with psychological support to mitigate the emotional toll of immobility on patients.

Question 5 of 5

A client with chronic obstructive pulmonary disease (COPD) is prescribed long-term oxygen therapy. What is the most important nursing consideration for this client?

Correct Answer: B

Rationale: Monitoring carbon dioxide levels (B) is critical in COPD clients on long-term oxygen therapy, as they may retain CO2, risking respiratory acidosis if oxygen suppresses their hypoxic drive (target SpO2 88-92%). Oxygen toxicity (A) is rare at low flows used in COPD. Humidification (C) enhances comfort but isn't the priority. Oxygen supply (D) is a general need, not COPD-specific. CO2 monitoring via ABGs or capnography ensures safe titration, preventing hypercapnia, a key consideration per COPD management guidelines like GOLD standards.

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