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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Correct Answer is C

Explanation

Rationale:
A. After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse: This technique assesses blood pressure, not pulse deficit. Pulse deficit requires comparing simultaneous heartbeats at different sites rather than using a cuff for measurement.

B. Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min: This evaluates orthostatic changes in heart rate, not pulse deficit. Pulse deficit specifically identifies a difference between apical and peripheral pulses during the same cardiac cycle.

C. Measure the client's apical pulse while another nurse measures their radial pulse: A pulse deficit is determined by counting the apical pulse and comparing it to the radial pulse simultaneously. A difference indicates that some heartbeats are not producing a palpable peripheral pulse, which is important in conditions like atrial fibrillation.

D. Assess both of the client's radial pulses at the same time and compare the quality of pulsations: Comparing radial pulses on both sides evaluates for peripheral pulse equality or arterial obstruction, not pulse deficit.

A. Obtain a prescription to refer the client to physical therapy. B. Instruct the client to wear sandals when ambulating. C. Encourage the client to dim the lights in hallways. D. Instruct the client to place throw rugs on bathroom floors.

Correct Answer is A

Explanation

Rationale:
A. Obtain a prescription to refer the client to physical therapy: A referral to physical therapy is appropriate because therapists can design individualized exercises to improve balance, coordination, and strength. This intervention promotes safe mobility, enhances independence, and reduces fall risk for clients with post-stroke weakness.

B. Instruct the client to wear sandals when ambulating: Sandals do not provide adequate foot support or traction and increase the risk of tripping or falling. Clients with right-sided weakness should wear well-fitting, non-skid shoes to ensure safety and stability during ambulation.

C. Encourage the client to dim the lights in hallways: Poor lighting impairs visibility and increases the risk of falls, especially for clients with weakness or gait instability. Adequate illumination in hallways and pathways is essential for safety during ambulation.

D. Instruct the client to place throw rugs on bathroom floors: Throw rugs are a major fall hazard due to their tendency to slip or bunch up. The nurse should advise removing rugs or securing them with non-slip backing to create a safe, stable walking environment.

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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

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