The nurse receives information about the assigned patients during shift report.
Which patient would the nurse assess first?
A patient who reports dizziness with a blood pressure (BP) of 150/92 mm Hg.
A patient who reports a severe headache and has begun vomiting.
A patient with a hip fracture who reports a pain level of 2 on a 1-to-10 scale.
A patient who received an angiotensin-converting enzyme (ACE) inhibitor 30 minutes previously and reports fatigue.
The Correct Answer is B
Choice A rationale:
Dizziness with a blood pressure of 150/92 mm Hg indicates hypertension, but it is not an immediate life-threatening condition requiring urgent assessment compared to a severe headache and vomiting.
Choice B rationale:
A severe headache and vomiting could be indicative of a serious neurological condition such as a stroke, intracranial bleeding, or increased intracranial pressure. This patient needs urgent assessment and intervention to prevent potential complications.
Choice C rationale:
A hip fracture with a pain level of 2 on a 1-to-10 scale suggests pain but is not immediately life-threatening compared to symptoms like severe headache and vomiting.
Choice D rationale:
Fatigue after receiving an ACE inhibitor is a common side effect and, while important to monitor, does not pose an immediate threat compared to the symptoms of severe headache and vomiting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice B rationale:
Conjunctival pallor is a common physical finding in patients with low hemoglobin levels (anemia), leading to paleness in mucous membranes such as the conjunctiva.
Choice C rationale:
Sternal tenderness is not a typical finding associated with low hemoglobin levels and is not directly related to anemia.
Choice D rationale:
A heart rate of 104 beats/min can be a compensatory response to anemia, as explained in .
Correct Answer is B
Explanation
Choice A rationale:
Dizziness with a blood pressure of 150/92 mm Hg indicates hypertension, but it is not an immediate life-threatening condition requiring urgent assessment compared to a severe headache and vomiting.
Choice B rationale:
A severe headache and vomiting could be indicative of a serious neurological condition such as a stroke, intracranial bleeding, or increased intracranial pressure. This patient needs urgent assessment and intervention to prevent potential complications.
Choice C rationale:
A hip fracture with a pain level of 2 on a 1-to-10 scale suggests pain but is not immediately life-threatening compared to symptoms like severe headache and vomiting.
Choice D rationale:
Fatigue after receiving an ACE inhibitor is a common side effect and, while important to monitor, does not pose an immediate threat compared to the symptoms of severe headache and vomiting.
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