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

Answer and Explanation

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.

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Correct Answer is ["A","D","E","G"]

Explanation

A. The client's nightmares could be indicative of post-traumatic stress disorder (PTSD), especially after the client’s parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago.
B. A heart rate of 99/min is within the normal range for the client’s age and requires no need for follow-up.
C. While regular attendance at school is generally considered a positive behavior, it does not directly indicate a need for immediate follow-up. However, it is relevant information for assessing the client's overall functioning and resilience in the context of their recent traumatic experience.
D. The client's use of marijuana as a coping mechanism raises concerns about their mental health and potential substance abuse. Immediate follow-up is needed to address this issue and provide appropriate support and intervention.
E. Startles easily during thunderstorms and witnessing their family's death are findings that indicate symptoms of post-traumatic stress disorder (PTSD) or acute stress reaction following the traumatic event of witnessing their family's death. Immediate follow-up is

necessary to assess the client's mental health status and provide appropriate support and counseling.
F. A blood pressure of 122/80 mm Hg falls within the normal range for adolescents and does not indicate an immediate medical concern. While blood pressure monitoring is important for overall health assessment, this finding alone does not warrant immediate follow-up in the context of the client's presenting issues.
G. The caregiver's observation that the client is acting differently than usual suggests a change in behavior or mental health status that requires further assessment and intervention. Immediate follow-up is needed to explore the caregiver's concerns and address any underlying issues affecting the client's well-being

A. Refer the family to a chronic pain support group. B. Request a change in medication from the provider. C. Review the child's electronic pain diary. D. Set up an appointment with the school nurse.

Correct Answer is C

Explanation

A. Referring the family to a chronic pain support group may be beneficial but does not address the immediate need to assess the child's current condition and management.
B. Requesting a change in medication from the provider may be necessary but should be based on a thorough assessment, including reviewing the child's pain diary.
C. Reviewing the child's electronic pain diary allows the nurse to gather important information about the frequency, severity, triggers, and effectiveness of current interventions for migraine headaches, guiding further assessment and management.
D. While involving the school nurse may be part of the child's care plan, it does not address the immediate need to assess the child's current condition and management.

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A nurse in the emergency department is receiving report on a group of clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in a clinic. Exhibits Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require follow-up.

Correct Answer is ["A","D","E","G"]

Explanation

A nurse is caring for a child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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