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
Explanation
A. Straining during defecation can stimulate the vagus nerve, which may lead to bradycardia (a decrease in heart rate). This is due to the increased intra-abdominal pressure affecting the autonomic nervous system.
B. Straining while defecating is not typically associated with the development of gastric ulcers; rather, ulcers are usually related to factors like Helicobacter pylori infection or NSAID use.
C. Straining while defecating is not related to causing diarrhea; rather, it often causes constipation or discomfort.
D. Straining while defecating is not associated with dilated pupils, which are typically affected by other factors such as drug use or neurological conditions.
Correct Answer is B
Explanation
A. At 2 months old, infants typically do not have the fine motor skills necessary to grasp objects intentionally. This skill usually develops around 4 to 6 months of age.
B. By 2 months of age, infants are expected to follow objects with their eyes as their visual tracking improves. This is a normal developmental milestone for this age.
C. Laughing and squealing are typically seen later, around 4 to 6 months of age. At 2 months, infants may coo and make other vocalizations but not laugh or squeal.
D. Rolling from back to side usually begins around 4 to 6 months of age. At 2 months, infants are generally not yet capable of this movement.
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