A nurse is caring for four clients. Which of the following assessment findings is the priority?
A client who has facial drooping following a stroke 8 hours ago.
A client who has a femur fracture and reports feeling short of breath.
A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10.
A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing.
The Correct Answer is B
The correct answer is choice B: A client who has a femur fracture and reports feeling short of breath.
Choice A rationale:
A client who has facial drooping following a stroke 8 hours ago (Choice A) is a concern as it may indicate neurological damage; however, a client with a femur fracture experiencing shortness of breath takes priority due to the potential risk of a pulmonary embolism, a life-threatening complication.
Choice B rationale:
A client who has a femur fracture and reports feeling short of breath (Choice B) is the priority assessment finding. Shortness of breath in this context raises concern for a possible pulmonary embolism, which is a critical condition that requires immediate intervention.
Choice C rationale:
A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10 (Choice C) is a valid concern, but it is of lower priority compared to a client with a femur fracture and respiratory distress.
Choice D rationale:
A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing (Choice D) is a normal postoperative finding and does not require immediate attention. While wound assessment is important, it is not the priority in this scenario.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The age of the client might impact the care plan, but it doesn't directly relate to the cost effectiveness of care. Older patients might have different health considerations, but the length of their stay and the services they require play a more significant role in cost evaluation.
Choice B rationale:
While the availability of community support groups can be beneficial for the client's overall well-being and recovery, it doesn't directly contribute to evaluating the cost effectiveness of care. Community support groups are more about psychosocial support than cost.
Choice C rationale:
This is the correct choice. The length of the client's stay directly affects the cost of care. Longer stays often involve more resources, medications, treatments, and staff time, leading to higher costs. Shorter and more efficient stays are generally more cost-effective.
Choice D rationale:
The type of insurance the client carries is relevant to the client's financial responsibility for their care, but it doesn't assist in evaluating the overall cost effectiveness of care. The insurance type might affect reimbursement rates, but it doesn't provide a comprehensive picture of cost efficiency.
Correct Answer is A
Explanation
Choice A rationale:
The child having red fissures at the corners of the mouth is not the priority finding. While this could indicate a nutritional deficiency, such as vitamin B2 (riboflavin) deficiency, the presence of bruises on the child's legs raises more immediate concerns related to potential physical abuse or safety issues.
Choice B rationale:
The child having several small bruises on both legs is the priority finding. Bruising on a school-age child could indicate physical abuse or an unsafe living environment. Ensuring the child's safety and well-being takes precedence over other findings. Assessing the nature, pattern, and explanation for the bruises is crucial.
Choice C rationale:
The child sleeping for about 13 hours each night is not the priority finding in this scenario. While sleep patterns are important, the potential for physical abuse and safety concerns associated with the bruises takes precedence.
Choice D rationale:
The child not regularly attending school is a concern, but it is not the priority finding when compared to the possibility of physical abuse indicated by the bruises. Both issues need to be addressed, but ensuring the child's immediate safety is the primary focus.
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