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A nurse in an emergency department is assessing four clients. Which of the following clients should the nurse see first?

A.

A client who reports a sudden onset of dizziness when sitting up

B.

A client who has new onset urticaria and angioedema

C.

A client who has numerous rectal polyps and blood-tinged stools

D.

A client who has a subluxation of the fifth digit on the left foot

Answer and Explanation

The Correct Answer is B

Rationale:

A. A client who reports a sudden onset of dizziness when sitting up: Although concerning, dizziness on position change may indicate orthostatic hypotension and is not immediately life-threatening. This client requires monitoring but is not the top priority based on airway or circulatory compromise.

B. A client who has new onset urticaria and angioedema: New urticaria and angioedema suggest a potential anaphylactic reaction, which can quickly progress to airway obstruction. This is a life-threatening emergency requiring immediate intervention to secure the airway and administer epinephrine.

C. A client who has numerous rectal polyps and blood-tinged stools: This condition could indicate a colorectal condition such as polyposis or malignancy, but it is not acutely life-threatening. The client needs evaluation, but not before those with airway or circulatory risks.

D. A client who has a subluxation of the fifth digit on the left foot: A subluxation is a partial dislocation, which can be painful but does not involve vital organ systems. This musculoskeletal issue is stable and can be addressed after more urgent needs are met.


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Related Questions

Correct Answer is B

Explanation

Rationale:

A. Fidelity: Fidelity involves loyalty, faithfulness, and keeping promises to individuals. While important in one-on-one nursing relationships, it is not the guiding principle when planning for population-wide benefit.

B. Utilitarianism: Utilitarianism is an ethical principle focused on producing the greatest good for the greatest number of people. It is most appropriate when planning community programs that aim to maximize overall health benefits.

C. Autonomy: Autonomy emphasizes respecting individual rights and decision-making. While vital in personal healthcare decisions, it does not directly guide broad community health program planning.

D. Veracity: Veracity refers to truth-telling and honesty in communication. Although essential in client interactions, it does not provide direction in choosing programs that broadly benefit the community.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Rationale for Correct Choices:

  • Pain level: The client reports severe epigastric pain radiating to the back with a pain score increasing from 7 to 9 out of 10. Managing this acute pain is critical to improve the client's comfort, reduce stress response, and help prevent complications such as respiratory distress caused by shallow breathing due to pain.
  • Blood pressure: The client’s blood pressure has dropped to 86/48 mm Hg, indicating hypotension that can lead to poor tissue perfusion and shock. After addressing pain, stabilizing blood pressure is essential to prevent organ dysfunction and maintain hemodynamic stability.

Rationale for Incorrect Choices:

  • Lung sounds: Although diminished breath sounds and rhonchi are concerning and may indicate complications, immediate pain control can improve respiratory effort and oxygenation before focusing on lung sounds.
  • Bowel sounds: Hypoactive bowel sounds are common in pancreatitis but are less urgent than pain and hypotension in acute care.
  • Temperature: Fever suggests infection or inflammation but is a lower priority compared to controlling pain and stabilizing blood pressure.
  • Blood glucose level: Elevated glucose requires monitoring but is less urgent than the client’s pain and hypotension in the acute phase.

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