The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first level priority problem?

Individual with a small laceration on the left forearm.

Individual with hypoactive bowel sounds and last bowel movement 6 days ago

Newly diagnosed patient with diabetes who needs diabetic teaching

Patient with 5/10 postoperative pain

Answer and Explanation

The Correct Answer is B

A.   A small laceration is typically a second-level priority, as it requires wound care but is not lifethreatening.
B.   This suggests a risk for bowel obstruction or other serious gastrointestinal issues that require immediate attention, making it a first-level priority.
C.   While important, this is not an urgent, life-threatening situation and is not considered a first-level priority.
D.   This is a second-level priority, as it requires pain management but is not as urgent as more critical issues.

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Correct Answer is D

Explanation

A. This grade indicates trace contraction but no movement. It is not appropriate in this case, as the patient has full range of motion.
B. Grade 2. This grade reflects full range of motion with gravity eliminated. The patient’s range of motion is against gravity, so this is not the correct grade.
C. Grade 3. This grade indicates full range of motion against gravity but without resistance. The patient is able to resist full force, so this is not the correct grade either.
D. Grade 5. This grade indicates normal strength with full range of motion against gravity and full resistance. This best describes the patient's strength, which is normal.

A. May indicate disease of the cerebellum or brainstem. B. is a sign that the patient is nervous about the examination C. Indicates a visual problem, and a referral to an ophthalmologist is indicated. D. is a normal occurrence

Correct Answer is A

Explanation

A. Severe nystagmus is often associated with neurological disorders, particularly those affecting the cerebellum or brainstem.
B. is a sign that the patient is nervous about the examination. Nervousness typically doesn’t cause severe, persistent nystagmus.
C. Indicates a visual problem, and a referral to an ophthalmologist is indicated. While nystagmus affects vision, it is usually neurologically based, requiring a neurological assessment rather than a referral to an ophthalmologist.
D. Nystagmus is not typically normal, especially when it is severe and persistent. It warrants further investigation.

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The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first level priority problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What grade of muscle strength should the nurse record using a 0- to 5-point scale?

Correct Answer is D

Explanation

During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes:

Correct Answer is A

Explanation

A nurse assesses four clients. Which client assessment will require the nurse to perform an immediate focused assessment?

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