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

A client who reports frequent and painful urination

A client who reports left arm pain following a fall

A client who has hypertension and reports a severe headache

A client who has heart failure and received a diuretic 30 min ago

Answer and Explanation

The Correct Answer is C

Rationale:
A. A client who reports frequent and painful urination: This client likely has a urinary tract infection, which requires assessment and treatment but is not immediately life-threatening.

B. A client who reports left arm pain following a fall: Pain from trauma requires evaluation, but unless there are signs of impaired circulation or severe injury, it is lower priority than potential neurologic emergencies.

C. A client who has hypertension and reports a severe headache: A severe headache in a client with hypertension may indicate a hypertensive crisis or impending stroke. Immediate assessment is required to prevent life-threatening complications, making this the highest priority.

D. A client who has heart failure and received a diuretic 30 min ago: Monitoring is necessary to assess diuretic effects, but this client is stable and does not require immediate intervention compared with the client at risk for hypertensive emergency.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"A,B,C"},"D":{"answers":"B,C"},"E":{"answers":"A,B"}}

Explanation

Rationale:

• Stool: The presence of blood and mucus in the stool (“currant jelly” stool) is classic for intussusception, caused by ischemia and mucosal sloughing of the affected bowel segment.

• Abdominal findings: A distended abdomen with a small, palpable, oblong mass in the right upper quadrant is characteristic of the telescoping bowel seen in intussusception.

• Pain rating: Severe, intermittent, colicky abdominal pain causing the child to draw knees to chest is hallmark of intussusception due to periodic intestinal obstruction and ischemia. Children with Crohn’s may report chronic mild to moderate pain, often intermittent. Pain in appendicitis is usually steady, localized and worsens over time.

• Vomiting : Vomiting is common in intussusception due to partial bowel obstruction, often light-colored and non-bilious in early stages. In appendicitis, nausea and vomiting are common early symptoms.

•Temperature: In Crohn's disease low-grade fever is common due to the chronic inflammatory process, while in appendicitis, low-grade fever is common due to inflammation or early infection.

A. The person holding financial power of attorney will make health care decisions based on the client's advance directives. B. The client has the right to refuse medical treatment, even if health care providers recommend it. C. If the client's advance directives are in writing and notarized, the client cannot change it in the future. D. The client's eldest adult child has the right to change advance directives in an end-of-life situation.

Correct Answer is B

Explanation

Rationale:
A. A financial power of attorney manages financial affairs, not medical decisions. Health care decisions are instead guided by a health care proxy or durable power of attorney for health care, as outlined in the client’s advance directives.

B. The Patient Self-Determination Act upholds the client’s autonomy by allowing them to accept or refuse medical or life-sustaining treatment. This includes the right to decline care, even if such refusal may lead to death, ensuring that personal values and wishes guide end-of-life care.

C. Advance directives can be revised or revoked by the client at any time, regardless of notarization, as long as the client remains mentally competent. The document reflects current wishes and is not legally binding indefinitely.

D. Family members cannot alter a legally valid advance directive. The document represents the client’s own decisions, and only the client can modify or revoke it while competent to do so.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care facility is caring for a toddler. Exhibits For each assessment finding below, click to specify if the assessment finding is consistent with Crohn's disease, appendicitis, or intussusception. Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"A,B,C"},"D":{"answers":"B,C"},"E":{"answers":"A,B"}}

Explanation

A nurse is caring for a client who is seeking information about end-of-life decisions. According to the Patient Self-Determination Act, which of the following applies to medical decisions that can be made within organizations that receive Medicare and Medicaid reimbursements?

Correct Answer is B

Explanation

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