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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Hemothorax: Hemothorax is accumulation of blood in the pleural space, typically caused by trauma, surgery, or ruptured vessels. Atrial fibrillation does not directly increase the risk of hemothorax.
B. Cardiac tamponade: Cardiac tamponade occurs when fluid accumulates in the pericardial sac, impairing cardiac output. This condition is usually associated with trauma, pericarditis, or post-surgical complications, not atrial fibrillation.
C. Pulmonary emboli: Atrial fibrillation can lead to stasis of blood in the atria, especially the left atrial appendage, increasing the risk of thrombus formation. If a clot dislodges and travels to the lungs, it can cause a pulmonary embolism, making this a serious complication to monitor for.
D. Widened pulse pressure: Widened pulse pressure reflects the difference between systolic and diastolic blood pressure and is associated with conditions like aortic regurgitation. It is not a direct consequence of atrial fibrillation and is not considered a primary risk in these clients.
Correct Answer is C
Explanation
Rationale:
A. Diminished breath sounds: Decreased breath sounds could indicate airway obstruction or respiratory compromise but are not a primary sign of hemorrhage following a tonsillectomy. They are more often associated with complications such as laryngospasm or mucus plugging rather than bleeding.
B. Increased drowsiness: Drowsiness in the postoperative period may result from the effects of anesthesia or pain medication. While important to monitor, it is not a specific indicator of hemorrhage unless accompanied by other symptoms like hypotension or tachycardia.
C. Frequent swallowing: Repeated swallowing is an early and classic sign of hemorrhage after tonsillectomy. Children often swallow blood draining down the throat instead of spitting it out, which can lead to blood loss and airway compromise if not promptly addressed.
D. Elevated pain level: Pain is expected after tonsil surgery and does not necessarily indicate bleeding. Although increasing pain should be assessed, it is not a reliable or specific sign of postoperative hemorrhage compared to frequent swallowing.
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