A nurse is prioritizing care for four clients.
Which of the following clients should the nurse assess first?
An adolescent who has sickle cell anemia and slurred speech.
An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10.
A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillin.
A toddler who has a partial-thickness burn on his right hand and requires a dressing change.
The Correct Answer is A
An adolescent who has sickle cell anemia and slurred speech should be assessed first.
Slurred speech can be a sign of a stroke, which is a known complication of sickle cell anemia.
This requires immediate medical attention.
Choice B is wrong because while pain management is important, it is not as urgent as a potential stroke.
Choice C is wrong because while administering medication is important, it is not as urgent as a potential stroke.
Choice D is wrong because while wound care is important, it is not as urgent as a potential stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Ataxia is a neurological sign that refers to a lack of muscle coordination and can cause staggering. Inhalation of gasoline vapors can cause symptoms such as dizziness or lightheadedness, headache, facial flushing, coughing or wheezing, staggering, slurred speech, blurry vision and weakness.
Choice B is wrong because Hypothermia is not an answer because hypothermia refers to a dangerously low body temperature and is not a symptom of gasoline inhalation.
Choice C is wrong because Hyperactive reflexes are not an answer because hyperactive reflexes refer to overactive or overresponsive reflexes and are not a symptom of gasoline inhalation.
Choice D is wrong because Pinpoint pupils are not an answer because pinpoint pupils refer to abnormally small pupils and are not a symptom of gasoline inhalation.
Correct Answer is D
Explanation
The accessory nerve is tested by evaluating the function of the trapezius and sternocleidomastoid muscles.
The trapezius muscle is tested by asking the patient to shrug their shoulders with and without resistance.
Choice A is wrong because following a light in the six cardinal positions tests the function of cranial nerves III, IV, and VI.
Choice B is wrong because moving their tongue in all directions tests the function of cranial nerve XII.
Choice C is wrong because showing their teeth while smiling tests the function of cranial nerve VII.
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