A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
A client who has active bleeding from a puncture wound to the groin area
A client who has a raised red skin rash on his arms, neck, and face
A client who reports shortness of breath and left shoulder and neck pain
A client who reports right-sided flank pain
The Correct Answer is C
A. A client with active bleeding from a puncture wound to the groin area requires immediate attention; however, the priority is determined by assessing the severity and potential complications associated with each condition.
B. A raised red skin rash could indicate an allergic reaction or infection, but it is not life-threatening compared to respiratory distress.
C. A client who reports shortness of breath and left shoulder and neck pain is the highest priority because these symptoms can indicate a serious condition, such as a myocardial infarction or pulmonary embolism. Both conditions require urgent assessment and intervention to prevent deterioration.
D. Right-sided flank pain can indicate kidney stones or other issues but is less critical than the risk of respiratory compromise present in option C.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Instituting rounds every 2 hours during the day to offer toileting can help prevent falls by addressing residents' toileting needs and reducing the risk of falls associated with attempting to ambulate to the bathroom independently.
b. Keeping four side rails up on the beds at night may increase the risk of entrapment and should be avoided as a fall prevention strategy.
c. Applying restraints, such as vest restraints, is not recommended as a fall prevention measure and may increase agitation and risk of injury.
d. While providing assistance during ambulation is important, it is not necessary to accompany all residents older than 85 years of age. Ambulation assistance should be provided based on individual assessment of mobility and fall risk.
Correct Answer is A
Explanation
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- A. Asking the client's son to go to the waiting area is the appropriate first step if elder abuse is suspected. It allows the nurse to speak with the client privately, which can help the client feel more secure and be more open about discussing sensitive issues such as abuse without fear of retaliation or immediate consequences.
B. Filing an incident report is an important step in documenting suspected abuse, but it should not be the first action taken. Documentation should occur after an initial assessment and gathering of information that supports the suspicion of abuse.
C. Treating and discharging the client may address the immediate physical health needs but does not address the potential safety concerns or the suspicion of abuse. Discharging the client back into a potentially harmful environment without further assessment or intervention could place the client at risk of further harm.
D. Asking the client about his injuries with the son present is not advisable if abuse is suspected. The presence of the potential abuser can influence the client's responses and may prevent the client from disclosing abuse due to fear or intimidation.
- A. Asking the client's son to go to the waiting area is the appropriate first step if elder abuse is suspected. It allows the nurse to speak with the client privately, which can help the client feel more secure and be more open about discussing sensitive issues such as abuse without fear of retaliation or immediate consequences.
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