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 has heart failure and received a diuretic 30 min ago
A client who has hypertension and reports a severe headache
A client who reports frequent and painful urination
A client who reports left arm pain following a fall
The Correct Answer is B
Rationale:
A. A client who has heart failure and received a diuretic 30 min ago: While this client should be monitored for urine output and signs of dehydration or electrolyte imbalance, there is no indication of acute distress requiring immediate attention.
B. A client who has hypertension and reports a severe headache: This could indicate a hypertensive crisis or impending stroke, both of which are life-threatening and require urgent assessment and intervention to prevent neurological damage or organ failure.
C. A client who reports frequent and painful urination: These are signs of a urinary tract infection, which, while uncomfortable, is not typically emergent unless accompanied by fever, flank pain, or systemic symptoms.
D. A client who reports left arm pain following a fall: The arm pain may indicate a fracture, but it is less urgent than potential end-organ damage from a hypertensive emergency, assuming no deformity or vascular compromise is described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "Your family disagrees with your decision?": This open-ended response reflects therapeutic communication by encouraging the client to express her feelings without judgment. It invites further discussion and shows the nurse’s support for the client’s autonomy and emotional well-being.
B. "Did you tell your provider that your family doesn't agree with your decision?": This response shifts focus away from the client's emotional conflict and places it on the provider. It may dismiss the client’s current need for support and hinder further emotional exploration.
C. "You are making the same decision I would make.": Personalizing the conversation undermines client autonomy. The nurse’s role is to support the client’s decision-making process, not impose personal opinions or make assumptions about what is best.
D. "You should get your family to agree with your decision before signing the consent.": This response suggests the client must yield to family opinions, which contradicts the principle of informed consent. The decision is ultimately the client’s, and family agreement is not a legal or ethical requirement.
Correct Answer is B
Explanation
Rationale:
A. Increased platelet count: Preeclampsia is often associated with thrombocytopenia (low platelet count), not an increase. A falling platelet count can be a warning sign of worsening disease or progression to HELLP syndrome.
B. Increased protein in urine: Proteinuria is one of the hallmark signs of preeclampsia, resulting from glomerular damage in the kidneys. A 24-hour urine protein test or dipstick is commonly used to detect elevated protein levels during pregnancy.
C. Decreased BUN: Blood urea nitrogen (BUN) may increase if renal perfusion is compromised, but a decrease is not typical in preeclampsia. Kidney involvement often leads to elevated BUN and creatinine levels.
D. Decreased serum uric acid: Preeclampsia usually causes elevated serum uric acid levels due to decreased renal clearance. A drop in uric acid would be inconsistent with this diagnosis
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