A nurse in the emergency department is receiving report on a group of clients. Which of the following clients should the nurse assess first?
A client who has Clostridium difficile and a temperature of 38.6° C (101.5° F)
A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10
A client who has left shoulder pain and S-T elevation on a 12-lead ECG
A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities
The Correct Answer is C
A. While a temperature elevation in a client with Clostridium difficile requires assessment, it is not as urgent as potential cardiac ischemia.
B. Pain assessment in a client with a femur fracture is important but does not take priority over potential cardiac issues.
C. Left shoulder pain with S-T elevation on an ECG can indicate myocardial infarction (MI), a life-threatening condition requiring immediate assessment and intervention.
D. Orthostatic hypotension and pitting edema, while concerning, do not indicate an acute, life-threatening condition that requires immediate assessment in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This advice may lead to inadequate emptying of the breasts and imbalance in milk production, potentially affecting milk supply and infant feeding.
B. Encouraging feeding on demand promotes effective breastfeeding by allowing the infant to feed when hungry, which helps establish and maintain milk supply. This approach supports infant cues and promotes successful breastfeeding.
C. Strict time limits on feeding can interfere with effective breastfeeding and hinder milk transfer, potentially leading to inadequate nutrition for the infant.
D. Water supplementation is unnecessary for breastfed infants and can interfere with breastfeeding by reducing infant appetite for breast milk.
Correct Answer is A
Explanation
A. Setting a routine, including a toileting schedule, helps manage incontinence and reduces confusion and anxiety for a client with dementia. Regular schedules provide structure and can improve cooperation and quality of life.
B. Simplifying clothing with easy fasteners like Velcro instead of buttons and zippers can help maintain independence in dressing for a person with dementia.
C. Physical activity should be encouraged as it can help reduce agitation, improve mood, and promote better sleep patterns.
D. Excessive sensory stimulation can be overwhelming and confusing for clients with dementia; activities should be calming and familiar.
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