A nurse is caring for four children in an emergency department.
Which of the following clients should the nurse assess first?

A child who has mononucleosis and reports severe fatigue.

A child who has Wilms' tumor and an abdominal mass.

A child who has acute epiglottitis and is drooling.

A child who has a urinary tract infection and bright red blood in her urine.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A child who has mononucleosis and reports severe fatigue requires medical attention, but this condition does not pose an immediate life-threatening risk compared to acute epiglottitis. Mononucleosis is a viral infection that can cause fatigue, sore throat, and swollen lymph nodes. While the child should be assessed, the priority is given to the child with acute epiglottitis due to the potential for airway obstruction and respiratory distress.

Choice B rationale:

A child who has Wilms' tumor and an abdominal mass also needs urgent medical evaluation. Wilms' tumor is a rare kidney cancer that primarily affects children. While it requires prompt attention, acute epiglottitis poses a more immediate threat to the airway and breathing.

Choice C rationale:

A child with acute epiglottitis and drooling requires immediate assessment and intervention. Acute epiglottitis is a potentially life-threatening infection that can cause severe swelling of the epiglottis, leading to airway obstruction. The child may have difficulty breathing and may present with the classic drooling sign due to the inability to swallow saliva. Prompt medical intervention, including airway management and appropriate antibiotics, is essential in this situation.

Choice D rationale:

A child with a urinary tract infection and bright red blood in her urine requires medical evaluation, but this condition is not as urgent as acute epiglottitis. Hematuria (blood in the urine) can have various causes, including urinary tract infections or kidney stones. While the child should receive medical attention, it does not take precedence over the immediate threat posed by acute epiglottitis, which requires urgent intervention to maintain the airway.

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Correct Answer is A

Explanation

Borderline.

A. Borderline personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affect, as well as marked impulsivity and recurrent suicidal behavior. The client's history of seeking counseling for relationship problems and selfinflicted lacerations are consistent with this disorder. Therefore, this choice is correct.
B. Antisocial personality disorder is characterized by a disregard for and violation of the rights of others, as well as a lack of remorse for one's actions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
C. Paranoid personality disorder is characterized by a pervasive distrust and suspiciousness of others, as well as a tendency to interpret others' motives as malevolent. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
D. Histrionic personality disorder is characterized by excessive emotionality and attentionseeking behavior, as well as a tendency to dramatize situations and exaggerate emotions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.

A. Begin ball squeezing exercises. B. Wear a bra with wire support. C. Avoid using the affected arm for eating. D. Use deodorant under the affected arm.

Correct Answer is C

Explanation

Choice A rationale:

Beginning ball squeezing exercises is not advisable immediately after a modified radical mastectomy. The client's arm on the affected side needs time to heal, and strenuous exercises can strain the surgical site, increase pain, and potentially disrupt the healing process.

Choice B rationale:

Wearing a bra with wire support is not recommended, especially in the early postoperative period. Underwire bras can irritate the surgical site and interfere with the healing process. Patients are usually advised to wear soft, non-underwire bras or special post-surgical bras designed for comfort and support.

Choice C rationale:

Avoiding the use of the affected arm for eating is the correct instruction. Protecting the surgical site and preventing strain is essential for proper healing. Encouraging the client to use the opposite arm for activities like eating can minimize movement in the affected area, reducing the risk of complications.

Choice D rationale:

Using deodorant under the affected arm is not recommended immediately after surgery. The surgical site needs to be kept clean and dry to prevent infection and promote healing. Deodorants, especially those containing chemicals or fragrances, can irritate the skin and increase the risk of complications. Patients are usually advised to avoid applying any products to the surgical area until it is fully healed.

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A nurse is caring for four children in an emergency department.Which of the following clients should the nurse assess first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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A nurse is caring for four children in an emergency department.
Which of the following clients should the nurse assess first?