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The nurse is caring for four clients. Which of these clients will the nurse see first?
A client with sudden and increasing pain in his fractured arm
A client with a fractured ankle who would like a glass of water
A client with rheumatoid arthritis and a scheduled pain medication
A client being discharged in two hours and needs to be taught how to use his crutches
The Correct Answer is A
Choice A reason: This is the highest priority client because sudden and increasing pain in a fractured arm can indicate a complication, such as compartment syndrome, infection, or nerve damage. Compartment syndrome is a condition where the pressure inside the muscles increases to dangerous levels, causing severe pain, reduced blood flow, and tissue death. Infection is a condition where microorganisms invade the wound site, causing inflammation, pus, and fever. Nerve damage is a condition where the nerves are injured by the fracture, causing numbness, tingling, or weakness. The nurse should see this client first and assess the arm for any signs of these complications, such as swelling, pallor, loss of sensation, or impaired movement. The nurse should also elevate the arm, loosen any bandages or casts, and administer pain medication as ordered.
Choice B reason: This is not the highest priority client because a fractured ankle is a common and stable condition that affects the lower extremity. A glass of water is a comfort and hydration need that can be met by the nurse or another staff member. The nurse should see this client after the more urgent clients and provide the glass of water, as well as monitor the ankle for any signs of complications, such as edema, infection, or impaired circulation.
Choice C reason: This is not the highest priority client because rheumatoid arthritis is a chronic and manageable condition that affects the joints. A scheduled pain medication is a routine and preventive need that can be met by the nurse or another staff member. The nurse should see this client after the more urgent clients and administer the pain medication, as well as assess the joints for any signs of inflammation, stiffness, or deformity.
Choice D reason: This is not the highest priority client because a discharge teaching is a discharge and education need that can be met by the nurse or another staff member. The nurse should see this client last and teach the client how to use the crutches, as well as provide any other discharge instructions, such as wound care, activity restrictions, or followup appointments.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Primary intention is the correct answer, because it is the type of wound healing that occurs when the wound edges are approximated and closed with sutures, staples, or glue. Primary intention is the fastest and most effective way of wound healing, as it minimizes tissue loss, infection, and scarring.
Choice B reason: Secondary intention is not the correct answer, because it is the type of wound healing that occurs when the wound edges are not approximated and left open to heal by granulation, contraction, and epithelialization. Secondary intention is the slowest and least effective way of wound healing, as it results in more tissue loss, infection, and scarring.
Choice C reason: Tertiary intention is not the correct answer, because it is the type of wound healing that occurs when the wound edges are initially left open and then closed with sutures, staples, or glue after a period of time. Tertiary intention is a delayed form of primary intention, and it is used when the wound is contaminated, infected, or requires drainage.
Choice D reason: Binary intention is not the correct answer, because it is not a real term for wound healing. Binary intention is a madeup term that does not describe any specific process or outcome of wound healing.
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: Sensory perception is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client can respond to pressurerelated discomfort or pain. Sensory perception can be affected by factors such as level of consciousness, spinal cord injury, or neuropathy. Sensory perception can influence the risk of pressure injuries, as clients with impaired sensory perception may not be able to feel or report the pressure, or change their position to relieve the pressure.
Choice B reason: Age is not one of the six subscales that will be utilized in a Braden Scale assessment, because it is not a direct or independent predictor of pressure injury risk. Age is a demographic variable that can be associated with other factors that affect the risk of pressure injuries, such as skin condition, mobility, or comorbidities. However, age itself is not a factor that is measured or scored in the Braden Scale assessment.
Choice C reason: Friction and shear is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client's skin is exposed to rubbing or sliding forces. Friction and shear can be affected by factors such as bed linens, transfers, or repositioning. Friction and shear can influence the risk of pressure injuries, as they can damage the skin and underlying tissues, or reduce the blood flow and oxygen delivery to the skin and tissues.
Choice D reason: Nutrition is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client's intake of food and fluids meets the body's needs. Nutrition can be affected by factors such as appetite, dentition, or swallowing. Nutrition can influence the risk of pressure injuries, as it can affect the skin integrity, wound healing, and immune function of the client.
Choice E reason: Mental state is not one of the six subscales that will be utilized in a Braden Scale assessment, because it is not a direct or independent predictor of pressure injury risk. Mental state is a psychological variable that can be associated with other factors that affect the risk of pressure injuries, such as sensory perception, mobility, or activity. However, mental state itself is not a factor that is measured or scored in the Braden Scale assessment.
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