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 D
Explanation
A. While the toddler may exhibit behaviors that seem related to the absence of the mother, the observed behavior is not specifically indicative of resentment toward the mother.
B. The behavior of sitting quietly and turning away from the nurse is more indicative of regression rather than a generalized anxiety reaction. Anxiety would be more evident through increased distress or agitation.
C. Developing autonomy would typically involve more exploration and independence rather than withdrawal and thumb-sucking, which are signs of regression.
D. Regression is a common reaction in toddlers to stress or significant changes, such as hospitalization. Behaviors like thumb-sucking and turning away from unfamiliar adults are signs of regressive behavior in response to the stress of separation from the primary caregiver.
Correct Answer is B
Explanation
A. Autism manifestations are not typically observed in neonates, as symptoms usually become more apparent in later developmental stages.
B. Autism spectrum disorder (ASD) is often identified in toddlers when developmental milestones, such as social interaction, communication, and play, show delays or atypical patterns.
C. Autism is not typically newly identified in middle-aged individuals. It is generally recognized in early childhood, though some individuals may be diagnosed later in life.
D. Autism is not associated with geriatric clients, as it is a developmental disorder identified in early childhood and does not present in the geriatric population.
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