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 A
Explanation
A. Footboard: A footboard helps maintain the foot in dorsiflexion and prevents it from pointing downward, which is essential in avoiding plantar flexion contractures in clients with limited mobility due to spinal cord injury.
B. Sheepskin heel pad: While this device helps reduce pressure and prevent skin breakdown on the heels, it does not provide structural support to keep the foot in the correct position and therefore does not prevent contractures.
C. Trochanter roll: A trochanter roll is placed alongside the outer thigh to prevent external rotation of the hip, not to support the foot or ankle. It is unrelated to plantar flexion prevention.
D. Abduction pillow: This is used to maintain proper hip alignment, especially after hip surgery. It does not provide support or positioning for the feet and is not effective for preventing foot contractures.
Correct Answer is C
Explanation
A. Polyuria: Polyuria results from hyperglycemia, where excess glucose in the bloodstream leads to osmotic diuresis. This causes the kidneys to excrete more water, increasing urination frequency. It is not a feature of hypoglycemia.
B. Fruity breath: Fruity-scented breath is due to ketone buildup in diabetic ketoacidosis, a complication of prolonged hyperglycemia. It signals metabolic acidosis rather than low blood sugar levels.
C. Diaphoresis: Diaphoresis occurs during hypoglycemia as the body releases epinephrine in response to falling glucose. This triggers sweating, tremors, and palpitations as part of the autonomic response.
D. Polyphagia: Polyphagia is a symptom of hyperglycemia, where cells are starved of glucose despite its presence in the blood. This leads to increased hunger, not typically seen in acute hypoglycemia.
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.