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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 C
Explanation
Choice A reason: Pulmonary embolism is not the correct answer, because it is a condition that affects the lungs, not the arm. Pulmonary embolism is a blockage of one or more arteries in the lungs by a blood clot, which can cause shortness of breath, chest pain, and coughing up blood.
Choice B reason: Ischial tuberosity is not the correct answer, because it is a bony projection on the pelvis, not the arm. Ischial tuberosity is the part of the pelvis that supports the weight of the body when sitting, and it can be injured by trauma, overuse, or infection.
Choice C reason: Compartment syndrome is the correct answer, because it is a condition that affects the arm, and it matches the symptoms of the client. Compartment syndrome is a serious complication of a traumatic injury, such as a fracture, that causes increased pressure within a closed space of the body, such as the forearm. This pressure can compromise the blood flow and nerve function of the affected area, causing pain, numbness, weakness, and pale skin.
Choice D reason: Broken arm syndrome is not the correct answer, because it is not a real medical condition. Broken arm syndrome is a madeup term that does not describe any specific diagnosis or treatment.
Correct Answer is C
Explanation
Choice A reason: "Tell me about what medications you are taking." is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Medications are part of the physical or pharmacological assessment, which focuses on the type, dose, frequency, and effectiveness of the drugs that the client is taking for rheumatoid arthritis. Medications may have some psychosocial implications, such as side effects, costs, or adherence, but they are not the main focus of the psychosocial assessment.
Choice B reason: "What physical limitations are you experiencing?" is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Physical limitations are part of the functional or mobility assessment, which focuses on the range of motion, strength, endurance, and coordination of the joints and muscles that are affected by rheumatoid arthritis. Physical limitations may have some psychosocial implications, such as pain, disability, or dependence, but they are not the main focus of the psychosocial assessment.
Choice C reason: "How does this impact your role in your family?" is the most appropriate statement by the nurse, because it is related to the psychosocial assessment. Role in the family is part of the social or relational assessment, which focuses on the interactions, responsibilities, and expectations of the client and their family members in relation to rheumatoid arthritis. Role in the family may have significant psychosocial implications, such as role changes, role conflicts, role strain, or role loss, which can affect the client's selfesteem, identity, and coping.
Choice D reason: "What therapies are you using to reduce swelling?" is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Therapies are part of the physical or nonpharmacological assessment, which focuses on the modalities, techniques, or devices that the client is using to manage the symptoms of rheumatoid arthritis. Therapies may have some psychosocial implications, such as availability, accessibility, or preference, but they are not the main focus of the psychosocial assessment.
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