A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?

A client who has a raised red skin rash on his arms, neck, and face

A client who has active bleeding from a puncture wound of the left groin area

A client who reports shortness of breath and left neck and shoulder pain

A client who reports right-sided flank pain and is diaphoretic

Answer and Explanation

The Correct Answer is B

Choice A reason: A client who has a raised red skin rash on his arms, neck, and face may have an allergic reaction or a skin infection, which are not life-threatening conditions. The nurse should monitor the client for signs of anaphylaxis or systemic infection, but this client is not the highest priority.

Choice B reason: A client who has active bleeding from a puncture wound of the left groin area is the highest priority because they are at risk of hemorrhage and shock. The nurse should apply direct pressure to the wound, elevate the affected leg, and monitor the client's vital signs and hemoglobin level.

Choice C reason: A client who reports shortness of breath and left neck and shoulder pain may have a cardiac or pulmonary problem, such as angina, myocardial infarction, or pulmonary embolism, which are serious conditions. The nurse should obtain an electrocardiogram, administer oxygen, and prepare for further diagnostic tests and interventions, but this client is not the highest priority.

Choice D reason: A client who reports right-sided flank pain and is diaphoretic may have a renal or urinary problem, such as kidney stones, pyelonephritis, or renal colic, which are painful but not life-threatening conditions. The nurse should administer analgesics, encourage fluid intake, and collect a urine sample, but this client is not the highest priority.

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Correct Answer is C

Explanation

Choice A reason: This is not the correct choice because this response is insensitive and unprofessional. The nurse should not blame or criticize the client for signing the consent form, as this may make the client feel guilty or pressured. The nurse should respect the client's autonomy and right to change their mind.

Choice B reason: This is not the correct choice because this response is inadequate and irrelevant. The nurse should not assume that the client needs more information about the surgery, as this may not address the client's underlying reasons for being unsure. The nurse should listen to the client's concerns and provide emotional support.

Choice C reason: This is the correct choice because this response is respectful and reassuring. The nurse should acknowledge the client's feelings and let them know that they have the option to cancel the surgery if they are not comfortable with it. The nurse should also inform the provider and the surgical team about the client's situation and facilitate further discussion if needed.

Choice D reason: This is not the correct choice because this response is inappropriate and unethical. The nurse should not offer medication to the client to help them relax, as this may impair their decision-making capacity and consent. The nurse should not coerce or manipulate the client to undergo the surgery.

A. "I cannot provide this information to you without your mother's consent." B. "What would you like to know about your mother's treatment?" C. "You will have to speak directly to your mother about her treatment." D. "I will ask your mother's primary care provider to speak with you."

Correct Answer is A

Explanation

Choice A reason: This is the correct response by the nurse. The nurse should respect the client's right to privacy and confidentiality and not disclose any information about the client's treatment plan without the client's consent. The nurse should also inform the adult child that they can ask their mother for permission to access her medical records.

Choice B reason: This is not the correct response by the nurse. The nurse should not ask the adult child what they want to know about the client's treatment, as this implies that the nurse is willing to share the information without the client's consent. The nurse should only answer the questions that the client has authorized the nurse to answer.

Choice C reason: This is not the correct response by the nurse. The nurse should not tell the adult child to speak directly to their mother about her treatment, as this may put pressure on the client to reveal information that she may not want to share. The nurse should respect the client's autonomy and decision-making regarding her treatment plan.

Choice D reason: This is not the correct response by the nurse. The nurse should not ask the client's primary care provider to speak with the adult child, as this may violate the client's privacy and confidentiality. The nurse should only involve the primary care provider if the client has given consent or if there is a legal or ethical obligation to do so.

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