A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
A client who reports right-sided flank pain and is diaphoretic
A client who reports shortness of breath and left neck and shoulder pain
A client who has active bleeding from a puncture wound of the left groin area
A client who has a raised red skin rash on his arms, neck, and face
The Correct Answer is B
A: Right-sided flank pain and diaphoresis could indicate a kidney stone or infection, which is painful but not immediately life-threatening.
B: Shortness of breath combined with pain in the neck and shoulder could suggest a myocardial infarction (heart attack), which is a medical emergency requiring immediate attention.
C: Active bleeding from a puncture wound is concerning and requires prompt intervention, but it may not be as immediately life-threatening as a potential heart attack.
D: A raised red skin rash could be a sign of an allergic reaction or infection. While it may require medical attention, it is not as urgent as a potential myocardial infarction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Collaborative, user-edited websites might contain varying levels of accuracy and reliability regarding medical information, making them less suitable for obtaining specific prevalence data.
B. An evidence-based nursing journal is a reliable source of information that often includes statistical data, prevalence rates, and updated research on various medical conditions, including Tay-Sachs disease.
C. The facility's case manager might have general information but may not provide specific prevalence rates for Tay-Sachs disease.
D. While the client's health care provider might have knowledge about Tay-Sachs disease, their primary focus during a clinical encounter might be the client's immediate care needs rather than providing statistics on disease prevalence.
Correct Answer is B
Explanation
A. It's not mandatory for a health care proxy to be a member of the client's family; the most important aspect is appointing someone the client trusts to make decisions on their behalf.
B. A health care proxy is someone designated by the client to make medical decisions when the client is unable to do so, based on the client's preferences and wishes.
C. While it's advisable to have an advance directive in place before procedures or when facing serious illnesses, the timing of appointing a health care proxy should not be confined to only these situations.
D. It is not necessary for an attorney to approve the appointment of a health care proxy; the client can designate someone they trust without legal counsel's approval.
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