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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Action: The action stage involves actively implementing strategies to change behavior, such as already using nicotine replacement therapy or abstaining from smoking. Since the client has not yet started quitting but intends to soon, they are not yet in this stage.
B. Contemplation: In this stage, the individual recognizes the need for change but has not yet committed to taking concrete steps. The client requesting a prescription and setting a quit date indicates they have moved beyond contemplation and are preparing for action.
C. Preparation: The preparation stage is characterized by planning to take action within the near future, usually within the next month. The client’s decision to quit within 2 weeks and request a nicotine patch reflects commitment and readiness to initiate behavior change, fitting this stage precisely.
D. Precontemplation: During precontemplation, the individual has no intention of changing behavior and may be unaware of the risks or resistant to advice. This does not apply to the client, who has already expressed motivation and plans to quit smoking soon.
Correct Answer is ["C","E","F","H"]
Explanation
Rationale for Correct Choices:
• Right forearm and fingers are edematous: Swelling after trauma can indicate a fracture, severe soft tissue injury, or early compartment syndrome. Prompt assessment and imaging are necessary to prevent complications such as impaired circulation or permanent tissue damage.
• Fingers slightly cool to touch: Cool fingers suggest compromised blood flow, possibly due to vascular injury or compartment syndrome. Immediate evaluation is critical to restore perfusion and prevent ischemic injury.
• Child can move fingers and reports a mild "tingling" sensation: Paresthesia signals potential nerve compression or early compartment syndrome. Timely intervention can prevent permanent nerve damage or loss of function.
• Multiple areas of bruising are noted on lower extremities in various stages of healing: Bruises in different stages of healing may indicate non-accidental trauma. This finding requires urgent reporting and investigation according to child protection policies.
Rationale for Findings Not Requiring Immediate Follow-Up
• Respirations easy and unlabored: Normal respiratory effort indicates that airway and oxygenation are adequate, so no immediate intervention is required.
• Abdomen non-distended: A soft, non-distended abdomen suggests no acute abdominal injury or internal bleeding, reducing the urgency of intervention.
• Ecchymotic area noted on outer aspect of the forearm: Localized bruising is consistent with the reported fall and mild trauma; it does not indicate immediate threat to circulation or nerve function.
• Child verbalizes a pain level of 4 on a scale of 0 to 10: Moderate pain is expected after minor trauma and can be managed with standard analgesics; it does not indicate an emergent complication.
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