A newly admitted patient is having generalized anxiety, headache with pain level 4/10, and shortness of breath at rest. How should the nurse prioritize these problems?
headache with pain level 4/10
Generalized anxiety
Shortness of breath
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"}}
Shortness of breath is a first-level priority because it is a potentially life-threatening issue. It requires immediate attention to ensure the patient is not experiencing an acute respiratory or cardiovascular event.
Headache with pain level 4/10 is a second-level priority because it is uncomfortable but not immediately life-threatening. The nurse should assess the cause of the headache, considering anxiety and other factors.
Generalized anxiety is a third-level priority as it does not pose an immediate threat to life, but should still be addressed to improve the patient’s comfort and well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. The ballottement test involves pressing on the knee joint to check for the presence of fluid, which can indicate joint effusion.
B. The McMurray test is used to assess for meniscal tears, not for fluid around the patella.
C. The Tinel sign is used to assess for nerve compression, not fluid accumulation.
D. The Phalen test is used to diagnose carpal tunnel syndrome, not to assess for joint effusion.
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