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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 ["A","C","E"]

Explanation

A. Swelling of the optic nerve: Swelling of the optic nerve, also known as papilledema, is a clear sign of increased intracranial pressure and indicates a worsening neurological condition. It results from pressure transmitted through the cerebrospinal fluid, leading to compromised optic nerve function.
B. Respiratory rate of 12/min: A respiratory rate of 12 breaths per minute is within normal limits for adults and does not indicate deterioration. While respiratory changes can be a late sign of increased ICP, a rate of 12 alone is not concerning.
C. Changes to pupil size and shape: Alterations in pupil size and shape often reflect pressure on cranial nerves, particularly the oculomotor nerve (CN III), which is a critical warning sign of brain herniation or increased ICP. This is a significant cue of neurologic decline.
D. Blood pressure of 108/74 mm Hg: This blood pressure reading is within a normal range and does not independently suggest a worsening neurologic condition. Worrisome signs would include widened pulse pressure or elevated systolic pressure, which may signal Cushing’s triad.
E. Decreasing Glasgow Coma scores: A drop in the Glasgow Coma Scale score indicates a decline in consciousness, which is a key sign of worsening intracranial pathology. Monitoring GCS trends is essential in patients with increased ICP to identify neurological deterioration early.

A. Cessation of hormonal supplements B. Dietary and fluid restrictions C. Cessation of intravenous (IV) drug use D. Encouraging increased mobility

Correct Answer is B

Explanation

A. Cessation of hormonal supplements: While hormonal supplements may be relevant in some heart failure cases, they are not typically the primary focus of discharge teaching for heart failure management. The main areas of concern are fluid management and diet.
B. Dietary and fluid restrictions: In heart failure, dietary restrictions, especially low-sodium diets, and fluid restrictions are crucial for preventing fluid overload and managing the symptoms of heart failure. Teaching clients to monitor their fluid intake and avoid excessive salt is essential for managing the condition.
C. Cessation of intravenous (IV) drug use: While avoiding IV drug use is generally beneficial for health, it is not specifically related to heart failure management. The primary focus should be on managing the fluid and dietary intake to prevent exacerbations of heart failure.
D. Encouraging increased mobility: While moderate exercise may be encouraged for heart failure patients, it should be done cautiously. Encouraging increased mobility without considering the client’s current condition could lead to overexertion and worsen symptoms. The priority is dietary and fluid management.

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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?

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Naxlex Comprehensive Predictor Exams

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