A nurse is prioritizing care for four clients.
Which of the following clients should the nurse assess first?
An adolescent who has sickle cell anemia and slurred speech.
An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10.
A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillin.
A toddler who has a partial-thickness burn on his right hand and requires a dressing change.
The Correct Answer is A
An adolescent who has sickle cell anemia and slurred speech should be assessed first.
Slurred speech can be a sign of a stroke, which is a known complication of sickle cell anemia.
This requires immediate medical attention.
Choice B is wrong because while pain management is important, it is not as urgent as a potential stroke.
Choice C is wrong because while administering medication is important, it is not as urgent as a potential stroke.
Choice D is wrong because while wound care is important, it is not as urgent as a potential stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A preschool-age child who has a muffled voice and no spontaneous cough should be assessed first.
These symptoms may indicate epiglottitis, which is a life-threatening condition that requires immediate medical attention.
Choice A, B and D are also important but not as urgent as choice C. A toddler with nephrotic syndrome and facial edema, an adolescent with Crohn’s disease and recent weight loss, and a school-age child with diabetes mellitus and a blood glucose of 200 mg/dL should be assessed after the preschool-age child with a muffled voice and no spontaneous cough.
Correct Answer is B
Explanation
Encourage physical activity as tolerated.
Children with sickle cell disease may need occasional rests from classroom activities but should be encouraged to participate in physical activity as tolerated.
Choice A is wrong because cold compresses are not recommended for pain management in sickle cell disease.
Choice C is wrong because there is no need for a child with sickle cell disease to wear a surgical mask to school.
Choice D is wrong because it is important for children with sickle cell disease to drink water throughout the day to avoid dehydration 1.
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