A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?
A toddler who has a laceration on his forehead and is crying
An adolescent female client who is belligerent and has slurred speech
A young adult with a painful sunburn of his face and arms
A middle adult male who is diaphoretic and reports epigastric pain
The Correct Answer is D
A. A laceration on the forehead of a toddler, while needing attention, is not as urgent as symptoms suggestive of a myocardial infarction.
B. Belligerence and slurred speech in an adolescent could indicate substance use or neurological issues, but it is less immediately life-threatening than symptoms of a myocardial infarction.
C. While painful sunburn can be uncomfortable, it is not as critical as symptoms indicative of a potential heart attack.
D. Diaphoresis and epigastric pain can be symptoms of a myocardial infarction (heart attack), which is a potentially life-threatening condition requiring immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D,E
Explanation
A. Trust vs. mistrust is the first stage of Erikson's psychosocial development, occurring from birth to approximately 18 months. During this stage, infants learn to trust their caregivers to meet their needs, leading to a sense of security.
B. Autonomy vs. shame and doubt is the second stage, occurring from approximately 18 months to 3 years. In this stage, toddlers learn to assert their independence by making choices and exercising self-control. Success leads to autonomy, while failure results in feelings of shame and doubt.
C. Initiative vs. guilt is the third stage, occurring from approximately 3 to 6 years. During this stage, children begin to take initiative in their activities, planning, and decision-making. Success in this stage leads to a sense of purpose, while failure can result in guilt over initiative taken.
D. Industry vs. inferiority is the fourth stage, occurring from approximately 6 to 12 years. In this stage, children develop a sense of industry by mastering tasks, succeeding in school, and receiving recognition. Failure to achieve this sense of industry can lead to feelings of inferiority.
E. Identity vs. role confusion is the fifth stage, occurring during adolescence. During this stage, individuals explore their personal identity, values, and beliefs. Success in this stage leads to a strong sense of identity, while failure results in role confusion and uncertainty about one’s place in society.
Correct Answer is B
Explanation
A. Walking without the monitoring unit is not an appropriate intervention during the test and may affect the accuracy of results.
B. Offering a snack, such as orange juice and crackers, can stimulate fetal movement and is a common intervention to ensure that the fetus is active during a nonstress test.
C. Immediate reporting and preparation for labor induction are not warranted based on the absence of fetal movement alone; the provider should first evaluate the situation.
D. While positioning can sometimes affect fetal activity, the absence of fetal movement for 15 minutes does not immediately necessitate changing the client's position.
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