A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?

A client who is postoperative and reports intermittent nausea

A client whose blood pressure is 160/90 mm Hg and reports a headache

A client who is scheduled for surgery in 2 hr

A client who is postoperative and has a Jackson-Pratt drain

Answer and Explanation

The Correct Answer is B

Hypertensive crisis is a severe increase in blood pressure that can lead to organ damage or other complications. Prompt assessment and intervention are necessary to prevent further escalation of blood pressure and potential complications.

While all the clients mentioned require attention, the client with elevated blood pressure and a headache poses a higher immediate risk. The nurse should assess the client's blood pressure, evaluate for signs of target organ damage, and initiate appropriate interventions, which may include administering antihypertensive medications as prescribed and monitoring closely for any changes in the client's condition.

The client who is postoperative and reports intermittent nausea can be assessed and managed after addressing the client with the elevated blood pressure and headache.

The client scheduled for surgery in 2 hours can be addressed according to the scheduled timeline.

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Correct Answer is A

Explanation

A. Chadwick’s sign

Chadwick's sign is a characteristic change that occurs during pregnancy, specifically in the cervix, vagina, and vulva. It is characterized by a bluish or purplish discoloration of these areas.

Chloasma in (option B) is incorrect because it is a condition characterized by the development of dark patches on the skin, commonly referred to as "mask of pregnancy." Chloasma typically affects the face, particularly the cheeks, forehead, and upper lip. It is not associated with a change in colour in the vaginal or vulvar area.

Hegar's sign in (option C) is incorrect because it is a softening of the lower uterine segment that can be felt during a pelvic examination. It is not related to the colour changes in the vaginal or vulvar area.

Ballottement in (option D) is incorrect because it is a palpation technique used during a prenatal examination to assess the position of the foetus. It involves the examiner gently pushing against the uterus and feeling a rebound or "floating" movement of the foetus. It does not involve changes in the colour of the vaginal or vulvar area.

A. Sarcoptes scabiei B. Human papillomavirus C. Neisseria gonorrhoeae D. Impetigo contagiosa

Correct Answer is C

Explanation

Neisseria gonorrhoeae is a sexually transmitted infection that is reportable to public health authorities due to its potential for spreading rapidly within a population and its significant public health implications. Reporting cases of Neisseria gonorrhoeae infection allows for appropriate monitoring, treatment, and control measures to be implemented to prevent further transmission and protect public health.

Sarcoptes scabiei, which causes scabies, is a contagious skin infestation but is not typically a reportable condition to the state health department.

Human papillomavirus (HPV) is a common sexually transmitted infection, but it is not generally reportable unless it is associated with certain high-risk strains and leads to specific conditions such as cervical cancer.

Impetigo contagiosa, a bacterial skin infection, is not usually a reportable condition unless there is an outbreak or unusual circumstances warranting public health intervention.

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A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?

Nursing Test Bank

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