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A nurse is assessing a group of clients. Which of the following clients should be categorized as Emergency Severity Index Level 1?

Client D ran out of diuretics yesterday. The client's blood pressure is 136/84, heart rate is 88/min, respiratory rate is 18/min, and pulse oximetry is 95%

Client B is obese and has right lower leg pain and swelling. The client's heart rate is 76/min and regular, blood pressure is 126/78, respiratory rate is 18/min, and pulse oximetry is 96%.

Client A reports dizziness and confusion. The client's heart rate is 120/min and irregular, blood pressure is 88/52, respiratory rate is 26/min, and pulse oximetry is82%

Client C reports a urinary tract infection (UTI). The client's heart rate is 72/min, blood pressure is 110/70, respiratory rate is 15/min, and pulse oximetry is 98%.

Answer and Explanation

The Correct Answer is C

A. Client D ran out of diuretics yesterday. The client's blood pressure is 136/84, heart rate is 88/min, respiratory rate is 18/min, and pulse oximetry is 95%: This client is stable with normal vital signs and does not show evidence of immediate life-threatening conditions. Although running out of diuretics may require prompt attention, it does not qualify as ESI Level 1.
B. Client B is obese and has right lower leg pain and swelling. The client's heart rate is 76/min and regular, blood pressure is 126/78, respiratory rate is 18/min, and pulse oximetry is 96%: This presentation could indicate a deep vein thrombosis, which is serious but not immediately life-threatening. The client is hemodynamically stable and does not meet the criteria for ESI Level 1.
C. Client A reports dizziness and confusion. The client's heart rate is 120/min and irregular, blood pressure is 88/52, respiratory rate is 26/min, and pulse oximetry is 82%: This client shows signs of hemodynamic instability, including hypotension, hypoxia, altered mental status, and an irregular, rapid heart rate. These findings indicate a critical condition requiring immediate life-saving interventions, qualifying the client for ESI Level 1.
D. Client C reports a urinary tract infection (UTI). The client's heart rate is 72/min, blood pressure is 110/70, respiratory rate is 15/min, and pulse oximetry is 98%: This client is stable with no signs of systemic or life-threatening complications. UTI symptoms can be uncomfortable but are not immediately life-threatening if vital signs are normal.

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Correct Answer is D

Explanation

A. Response to noxious stimuli: While assessing the response to noxious stimuli can be an important part of neurological assessment, it is not specific to mild traumatic brain injury (TBI). The primary focus should be on cranial nerve assessment to evaluate brain function and detect any early signs of deterioration.
B. Obstructive sleep apnea: Obstructive sleep apnea is not a typical concern for a client with mild TBI. The focus should be on the immediate effects of the injury, such as cranial nerve function, rather than conditions unrelated to the head injury.
C. Trousseau's sign: Trousseau's sign is a test used to assess for latent tetany (muscle spasms), typically in cases of hypocalcemia. It is not relevant for a client with mild TBI unless there are other symptoms indicating electrolyte imbalances, which are not the primary concern in this case.
D. Cranial nerve assessment: Cranial nerve assessment is a key part of evaluating the neurological status of a client with mild TBI. It helps identify any deficits or changes in brain function that may indicate deterioration or more severe injury. This should be part of the plan of care for a mild TBI client.

A. Lower oxygen saturations of 93% to 94% B. Lower energy expenditure C. Higher oxygen saturations of 98% to 99% D. Increased lung capacity

Correct Answer is A

Explanation

A. Lower oxygen saturations of 93% to 94%: Older adults with pneumothorax may present with lower oxygen saturations as the collapsed lung leads to impaired gas exchange. Oxygen saturation levels of 93% to 94% may indicate mild hypoxemia in these clients.
B. Lower energy expenditure: Pneumothorax in older adults is more likely to result in respiratory symptoms like hypoxemia, rather than directly affecting energy expenditure.
C. Higher oxygen saturations of 98% to 99%: This is unlikely in the presence of pneumothorax, which typically causes hypoxemia due to impaired lung function. High oxygen saturation levels would not be expected.
D. Increased lung capacity: Pneumothorax causes lung collapse, which results in decreased lung capacity and is not associated with increased lung function.

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A nurse is assessing a group of clients. Which of the following clients should be categorized as Emergency Severity Index Level 1?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a mild traumatic brain injury (TBI). Which of the following should the nurse include in the plan of care?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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