A nurse is caring for four clients in an emergency department. The nurse should plan to see which of the following clients first?
A client who is confused, is febrile and has foul-smelling urine
A client who has sickle cell disease and reports severe joint pain
A client who has slurred speech, is disoriented, and reports a headache
A client who has a dislocated left shoulder
The Correct Answer is C
A. A client who is confused, is febrile, and has foul-smelling urine: These symptoms suggest a urinary tract infection potentially progressing to sepsis, which is serious but does not take priority over signs of possible stroke or brain injury.
B. A client who has sickle cell disease and reports severe joint pain: Severe pain is expected in sickle cell crises and requires prompt management, but it is not as time-sensitive as neurologic deterioration.
C. A client who has slurred speech, is disoriented, and reports a headache: These findings suggest a possible stroke or other neurological emergency such as a brain hemorrhage or increased intracranial pressure, which requires immediate evaluation and intervention.
D. A client who has a dislocated left shoulder: Although painful and requiring attention, a shoulder dislocation is not immediately life-threatening and does not take precedence over potential neurologic compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F","G"]
Explanation
Rationale for Correct Choices:
- DTR 2+ bilaterally: The deep tendon reflexes improved from 1+ earlier (indicating possible magnesium toxicity) to 2+, which falls within the normal range of 1+ to 3+. This suggests better neuromuscular function and reduced magnesium side effects.
- Urine output 40 mL/hr: Increased from a low 20 mL/hr at 1400 to 40 mL/hr at 1800, above the normal minimum urine output (>30 mL/hr). This reflects improved renal perfusion and fluid balance, crucial for preventing complications in preeclampsia.
- Oxygen saturation 95% on 2 L nasal cannula: Oxygen saturation stabilized at 95%, which is the lower limit of normal (95–100%). Previously it was 92% on room air, indicating improved oxygenation with supplemental oxygen support.
- Respiratory rate 18/min: Improved from shallow respirations at 14/min to 18/min, which falls within the normal adult range (12–20/min). This indicates better respiratory effort and gas exchange.
- Blood pressure 146/96 mm Hg: Decreased from a hypertensive crisis level of 170/112 mm Hg at 1400 to 146/96 mm Hg, showing effective blood pressure management though still above the ideal (<120/80 mm Hg). This reduction lowers the risk of severe complications.
Rationale for Incorrect Choices:
- Temperature 38.3° C (101° F): Elevated above the normal range (36.5–37.5° C), this fever suggests possible infection or inflammatory response and does not represent clinical improvement. It requires further evaluation and treatment.
- Heart rate 58/min: Decreased from 80/min to 58/min, falling below the normal range of 60–100/min. This bradycardia may be a sign of magnesium toxicity or cardiovascular suppression and requires close monitoring.
Correct Answer is A
Explanation
A. “It sounds like you're saying that you feel uncomfortable around others.": This therapeutic response reflects the client's feelings and encourages further expression, showing empathy without judgment or assumption.
B. “How long have you struggled with your weight?": This question shifts the focus to the client’s weight history rather than their current emotional distress, which may feel dismissive or overly clinical.
C. “Have you always felt uncomfortable being overweight?": This response makes assumptions about the client's feelings and can come across as insensitive, which may inhibit open communication.
D. “Let's discuss some weight loss strategies that might work for you.”: Offering solutions too early may invalidate the client’s emotions and shift the focus away from addressing their immediate feelings of embarrassment and discomfort.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.