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. Decreased level of consciousness is a critical finding in a client with meningitis and may indicate worsening intracranial pressure or neurological deterioration, requiring immediate intervention.
b. While an increased temperature may indicate infection, it is not as immediately concerning as a decreased level of consciousness in a client with meningitis.
c. A generalized rash over the trunk may be present in some types of meningitis, but it is not as immediately urgent as a decreased level of consciousness.
d. Photophobia (sensitivity to light) is a common symptom of meningitis but may not require immediate intervention unless accompanied by other concerning neurological findings such as a decreased level of consciousness.
Correct Answer is D
Explanation
A. Collaborating involves working together with all parties to find a mutually beneficial solution. This approach values input from others and seeks consensus, which is not demonstrated in the scenario.
B. Cooperating typically refers to acknowledging and accommodating others' concerns while trying to maintain relationships. The nurse manager’s approach does not reflect this strategy, as she is disregarding opposing feelings.
C. Compromising seeks a middle ground where both parties can give and take to reach an agreement. The nurse manager's unilateral decision-making does not align with compromising.
D. Competing is characterized by an assertive and uncooperative stance, where one party seeks to impose their preferred solution without regard for others’ input or feelings. The nurse manager’s decision to implement changes despite opposition exemplifies this strategy.
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