A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?
A toddler who has a laceration on his forehead and is crying
An adolescent female client who is belligerent and has slurred speech
A young adult with a painful sunburn of his face and arms
A middle adult male who is diaphoretic and reports epigastric pain
The Correct Answer is D
A. A laceration on the forehead of a toddler, while needing attention, is not as urgent as symptoms suggestive of a myocardial infarction.
B. Belligerence and slurred speech in an adolescent could indicate substance use or neurological issues, but it is less immediately life-threatening than symptoms of a myocardial infarction.
C. While painful sunburn can be uncomfortable, it is not as critical as symptoms indicative of a potential heart attack.
D. Diaphoresis and epigastric pain can be symptoms of a myocardial infarction (heart attack), which is a potentially life-threatening condition requiring immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A negative contraction stress test (CST) indicates that there is no evidence of uteroplacental insufficiency, as the fetal heart rate does not show decelerations with contractions.
B. The number of contractions is not the defining criterion for a negative CST.
C. The absence of accelerations is not related to the interpretation of a CST. The test is focused on fetal heart rate decelerations in response to contractions.
D. Cervical incompetence is not assessed through a contraction stress test; it is typically evaluated through cervical length measurements and history.
Correct Answer is B
Explanation
A. At 2 months old, infants typically do not have the fine motor skills necessary to grasp objects intentionally. This skill usually develops around 4 to 6 months of age.
B. By 2 months of age, infants are expected to follow objects with their eyes as their visual tracking improves. This is a normal developmental milestone for this age.
C. Laughing and squealing are typically seen later, around 4 to 6 months of age. At 2 months, infants may coo and make other vocalizations but not laugh or squeal.
D. Rolling from back to side usually begins around 4 to 6 months of age. At 2 months, infants are generally not yet capable of this movement.
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