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.
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Related Questions
Correct Answer is A
Explanation
- Rationale for A: Client confidentiality is a fundamental part of nursing ethics and legal practice. A nurse may disclose information to a family member only if the client has given permission, ensuring respect for the client's autonomy and privacy.
- Rationale for B: While it is true that nurses play a crucial role in patient education, the primary responsibility for informing clients about treatment options lies with the attending physician or healthcare provider.
- Rationale for C: The use of restraints is highly regulated in healthcare settings. Restraints can only be applied based on specific criteria and orders that are not on a PRN (as needed) basis, to protect the safety and rights of the client.
- Rationale for D: Administering medications without consent, even as part of a research study, is unethical and illegal unless specific and stringent consent procedures are followed, which include informed consent and approval by an institutional review board (IRB).
Correct Answer is A
Explanation
a. An evidence-based nursing journal would provide reliable, peer-reviewed information on the prevalence of Tay-Sachs disease, ensuring accuracy and reliability.
b. While the client's health care provider may have general knowledge about Tay-Sachs disease, they may not have specific prevalence statistics readily available.
c. The facility's case manager may assist with coordination of care but may not have specific information about the prevalence of Tay-Sachs disease.
d. Collaborative, user-edited websites may not always provide accurate or reliable information, so they should be used with caution for obtaining medical information.
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