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 D
Explanation
A. Uteroplacental insufficiency typically causes late decelerations, which occur after the peak of a contraction due to inadequate blood flow to the placenta.
B. Fetal head compression typically causes early decelerations, which mirror the contraction pattern and occur at the peak of the contraction.
C. While IV narcotics can affect fetal heart rate, variable decelerations are not specifically related to their administration.
D. Variable decelerations are commonly caused by umbilical cord compression, which can disrupt blood flow and lead to a variable drop in fetal heart rate that is not consistently timed with contractions.
Correct Answer is A
Explanation
A. Facial edema is a potential warning sign during pregnancy that could indicate preeclampsia, especially when it occurs suddenly or is accompanied by other symptoms such as hypertension or proteinuria. This condition requires prompt medical evaluation.
B. Nausea and vomiting are common discomforts during the first trimester, often referred to as morning sickness. While they can be bothersome, they are generally not a cause for concern unless they become severe and lead to dehydration, in which case the client should seek medical advice.
C. Leukorrhea, or increased vaginal discharge, is a common and typically harmless discomfort during pregnancy due to hormonal changes. It does not usually indicate a problem unless it is accompanied by itching, odor, or changes in color, which might suggest infection.
D. Urinary frequency is a common symptom during the first trimester of pregnancy due to hormonal changes and the growing uterus pressing on the bladder. While it can be uncomfortable, it is not considered a danger sign unless associated with symptoms of a urinary tract infection, such as pain or burning during urination.
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