A nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first?
A child who has acute epiglottitis and is drooling
A child who has mononucleosis and reports severe fatigue
A child who has Wilms' tumor and an abdominal mass
A child who has a urinary tract infection and bright red blood in their urine
The Correct Answer is A
A. A child who has acute epiglottitis and is drooling: Acute epiglottitis is a medical emergency that can rapidly progress to airway obstruction and respiratory distress. Drooling is a significant sign of airway compromise in children with epiglottitis due to swelling of the epiglottis. This child requires immediate assessment and intervention to ensure airway patency.
B. A child who has mononucleosis and reports severe fatigue: While mononucleosis can cause severe fatigue, it is not an immediate life-threatening condition compared to acute epiglottitis. Assessment and intervention for severe fatigue can be prioritized after addressing the child with potential airway compromise.
C. A child who has Wilms' tumor and an abdominal mass: Wilms' tumor is a type of kidney cancer that typically presents with an abdominal mass. While it requires timely medical intervention, it is not as urgent as acute epiglottitis, which poses a risk of airway obstruction.
D. A child who has a urinary tract infection and bright red blood in their urine: While a urinary tract infection with hematuria requires assessment and treatment, it is not immediately life-threatening compared to acute epiglottitis. Addressing the child with potential airway compromise takes precedence over evaluating and managing hematuria.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Provide the client with a list of eligible individuals who can serve as a health care proxy. - While it is important for clients to have information about selecting a healthcare proxy, the Patient Self-Determination Act does not specifically require nurses to provide a list of eligible individuals. However, nurses should educate clients about their rights to designate a healthcare proxy if desired.
B. Document in the client's medical record if the client has advance directives. - This is the correct action required by the Patient Self-Determination Act. The act mandates that healthcare facilities receiving Medicare or Medicaid funds must inform clients about their rights to make decisions about their medical care, including the right to have advance directives. Nurses are responsible for documenting in the client's medical record whether the client has advance directives, such as a living will or durable power of attorney for healthcare.
C. Provide end-of-life education if the client has a terminal illness. - While providing end-of-life education is important for clients with terminal illnesses, it is not specifically mandated by the Patient Self-Determination Act. However, the act does require healthcare facilities to inform clients about their rights to make decisions about end-of-life care, including the right to have advance directives.
D. Ensure the client has an attorney to contact for assistance with end-of-life documents. - The Patient Self-Determination Act does not mandate that nurses ensure clients have an attorney for assistance with end-of-life documents. While legal assistance may be helpful for some clients in completing advance directives, it is not a requirement of the act.
Correct Answer is C
Explanation
A. Hazelnuts: While hazelnuts are a common allergen, they are not typically associated with cross-sensitivity to latex. Therefore, further assessment for cross-sensitivity to hazelnuts is not necessary based solely on the child's latex allergy.
B. Almonds: Similar to hazelnuts, almonds are a common allergen but are not typically associated with cross-sensitivity to latex. Therefore, further assessment for cross-sensitivity to almonds is not necessary based solely on the child's latex allergy.
C. Bananas: Bananas are one of the most common foods associated with latex allergy cross-sensitivity. Many individuals with latex allergy may also experience allergic reactions to bananas due to shared allergenic proteins. Therefore, further assessment for cross-sensitivity to bananas is warranted in this case.
D. Strawberries: While strawberries are a common allergen, they are not typically associated with cross-sensitivity to latex. Therefore, further assessment for cross-sensitivity to strawberries is not necessary based solely on the child's latex allergy.
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