A client arrives in the Emergency Department via ambulance with the following signs: central cyanosis, HR 42, BP 80/50. What priority level should the nurse identify for this client?
Third level priority
First level priority
Routine
Second level priority
The Correct Answer is B
A. This category refers to non-urgent problems, which does not apply here as the client is showing signs of severe distress and requires immediate attention.
B. Central cyanosis, a low heart rate (bradycardia), and low blood pressure are life-threatening signs that necessitate immediate intervention to stabilize the patient.
C. This is not a routine or minor situation. The client is in critical condition and requires urgent intervention.
D. While second-level priorities are important, this patient has life-threatening signs requiring first-level priority, immediate action, and stabilization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The trochlear nerve controls the superior oblique muscle of the eye and is not related to facial movements.
B. The abducens nerve controls the lateral rectus muscle of the eye, responsible for eye movement, not facial muscles.
C. The vagus nerve affects the soft palate, pharynx, and larynx, but does not contribute to facial expression.
D. Asymmetry in facial movements, like smiling, frowning, and puffing the cheeks, suggests dysfunction of the facial nerve (CN VII).
Correct Answer is C
Explanation
A. Flexion involves decreasing the angle between two body parts, such as bending the knee or elbow, not moving the leg laterally.
B. Abduction is the movement of a body part away from the midline of the body. In this case, moving the leg laterally fits this description.
C. Adduction refers to movement toward the body's midline, the opposite of abduction.
D. Extension involves straightening a body part, such as straightening the knee, which does not match the description of moving the leg laterally and medially.
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