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 B
Explanation
A. A weight gain of 25 to 35 pounds is recommended for women with a normal BMI (18.5–24.9). The client in this scenario has a BMI of 26.5, which places her in the overweight category.
B. The recommended weight gain for a client with a BMI of 25–29.9 (overweight) is 15 to 25 pounds. This amount of weight gain helps reduce the risk of complications such as gestational diabetes and hypertension.
C. While gaining 1 pound per week might be appropriate in the second and third trimesters, it doesn't specify the total recommended weight gain, which is more critical for a client with a BMI of 26.5.
D. A weight gain of 11 to 20 pounds is recommended for women with a BMI of 30 or higher (obese), not for those in the overweight category.
Correct Answer is A
Explanation
A. Ambivalence and doubts are normal responses in early pregnancy due to the significant life changes and emotional adjustments. Acknowledging that these feelings are common helps validate the client's experience and provides reassurance.
B. While counseling might be beneficial if feelings persist or worsen, suggesting it immediately might not address the client's current emotional needs or normalize her experience.
C. Telling the client not to worry and that she will be fine once the baby is born dismisses her current feelings and does not provide appropriate support.
D. Although discussing feelings with a trusted family member might be helpful, suggesting this as a primary response does not address the client's immediate emotional concerns or validate her feelings.
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