NCLEX Practice Test

Which client should the nurse assess first during handoff of care report?

1. Client who had an emergency appendectomy 48 hours ago and is reporting hearing waves and seeing fish swimming through the walls

2. Client who had an exploratory laparoscopy 2 hours ago and has absent bowel sounds

3. Client with diabetes mellitus who has a foot ulcer and is reporting feeling pins and needles in the lower legs

4. Client with Parkinson disease who has tremors while resting

The correct answer is: Client who had an emergency appendectomy 48 hours ago and is reporting hearing waves and seeing fish swimming through the walls

The client who had an emergency appendectomy 48 hours ago and is reporting hearing waves and seeing fish swimming through the walls presents with symptoms that are concerning for potential delirium, hallucinations, or altered mental status, which can indicate a serious underlying issue such as infection, metabolic imbalance, or medication side effects. These symptoms require immediate assessment to ensure the client's safety and to determine the cause of their altered perception. While the other clients may also have significant needs, the immediate priority for this client is the potential for acute issues that could quickly escalate if not addressed, particularly given the recent surgical history. Monitoring mental status changes after surgery is crucial, as they can indicate complications that may not be overtly physical but are nonetheless critical to patient wellbeing.