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A nurse is assessing a group of clients. Which of the following clients should be categorized as Emergency Severity Index Level 1?

Client D ran out of diuretics yesterday. The client's blood pressure is 136/84, heart rate is 88/min, respiratory rate is 18/min, and pulse oximetry is 95%

Client B is obese and has right lower leg pain and swelling. The client's heart rate is 76/min and regular, blood pressure is 126/78, respiratory rate is 18/min, and pulse oximetry is 96%.

Client A reports dizziness and confusion. The client's heart rate is 120/min and irregular, blood pressure is 88/52, respiratory rate is 26/min, and pulse oximetry is82%

Client C reports a urinary tract infection (UTI). The client's heart rate is 72/min, blood pressure is 110/70, respiratory rate is 15/min, and pulse oximetry is 98%.

Answer and Explanation

The Correct Answer is C

A. Client D ran out of diuretics yesterday. The client's blood pressure is 136/84, heart rate is 88/min, respiratory rate is 18/min, and pulse oximetry is 95%: This client is stable with normal vital signs and does not show evidence of immediate life-threatening conditions. Although running out of diuretics may require prompt attention, it does not qualify as ESI Level 1.
B. Client B is obese and has right lower leg pain and swelling. The client's heart rate is 76/min and regular, blood pressure is 126/78, respiratory rate is 18/min, and pulse oximetry is 96%: This presentation could indicate a deep vein thrombosis, which is serious but not immediately life-threatening. The client is hemodynamically stable and does not meet the criteria for ESI Level 1.
C. Client A reports dizziness and confusion. The client's heart rate is 120/min and irregular, blood pressure is 88/52, respiratory rate is 26/min, and pulse oximetry is 82%: This client shows signs of hemodynamic instability, including hypotension, hypoxia, altered mental status, and an irregular, rapid heart rate. These findings indicate a critical condition requiring immediate life-saving interventions, qualifying the client for ESI Level 1.
D. Client C reports a urinary tract infection (UTI). The client's heart rate is 72/min, blood pressure is 110/70, respiratory rate is 15/min, and pulse oximetry is 98%: This client is stable with no signs of systemic or life-threatening complications. UTI symptoms can be uncomfortable but are not immediately life-threatening if vital signs are normal.

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Correct Answer is B

Explanation

A. "Your heart condition is caused when the ventricular tissue becomes fibrous and fatty": This description aligns more with restrictive cardiomyopathy. Dilated cardiomyopathy (DCM) involves the enlargement and weakening of the ventricles rather than fibrous or fatty tissue replacement.
B. "Your heart condition is caused by excessive stretching of the ventricles": Dilated cardiomyopathy is characterized by the excessive stretching of the ventricles, leading to poor contraction and reduced pumping efficiency. This is the most accurate explanation of the condition.
C. "Your heart condition is caused by thickening of the ventricular walls and septum": This description refers to hypertrophic cardiomyopathy, not dilated cardiomyopathy. Hypertrophic cardiomyopathy is characterized by thickened heart walls, not dilation.
D. "Your heart condition is caused from stiffening of the walls of the ventricles": This description refers to restrictive cardiomyopathy, where the heart walls become stiff and less able to expand and contract properly, not dilated cardiomyopathy.

A. Discussing organ donation with the family B. Communicating sensitively with the client and family C. Creating a plan for pain relief, nutrition, and hydration D. Contacting the family's spiritual advisor

Correct Answer is B

Explanation

A. "Discussing organ donation with the family": While organ donation is important, it is not the priority in the setting of an actively dying client. The primary concern at this stage should be addressing the immediate needs of the client and their family, focusing on emotional support and comfort.
B. "Communicating sensitively with the client and family.": When caring for a client who is actively dying, providing emotional support and clear communication with the family is critical. Sensitively addressing the family’s concerns and the client’s comfort is essential in this stage of care.
C. "Creating a plan for pain relief, nutrition, and hydration.": While ensuring pain relief is important, in the context of an actively dying patient, the focus should primarily be on comfort rather than ongoing interventions like nutrition and hydration, which may no longer be beneficial.
D. "Contacting the family's spiritual advisor.": While spiritual support is valuable, it should not be the first priority. Ensuring the client’s comfort and providing emotional support to the family should be prioritized initially, and the spiritual advisor can be contacted afterward if desired.

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A nurse is assessing a group of clients. Which of the following clients should be categorized as Emergency Severity Index Level 1?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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