A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
A client who reports right-sided flank pain and is diaphoretic
A client who reports shortness of breath and left neck and shoulder pain
A client who has active bleeding from a puncture wound of the left groin area
A client who has a raised red skin rash on his arms, neck, and face
The Correct Answer is B
A: Right-sided flank pain and diaphoresis could indicate a kidney stone or infection, which is painful but not immediately life-threatening.
B: Shortness of breath combined with pain in the neck and shoulder could suggest a myocardial infarction (heart attack), which is a medical emergency requiring immediate attention.
C: Active bleeding from a puncture wound is concerning and requires prompt intervention, but it may not be as immediately life-threatening as a potential heart attack.
D: A raised red skin rash could be a sign of an allergic reaction or infection. While it may require medical attention, it is not as urgent as a potential myocardial infarction.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Implementing a fall prevention plan is an important step but comes after identifying those at risk.
B. Reviewing current literature is important for understanding evidence-based practices, but it should come after identifying and assessing the specific risk factors in the facility.
C. Notifying staff of the increased fall rate is essential but doesn't directly address the root cause; it's more reactive than proactive.
D. Identifying clients who are at risk for falls is the initial step to intervene and prevent further incidents, forming the foundation for a targeted fall prevention plan.
Correct Answer is B
Explanation
A. A client ready for discharge, if stable and prepared for discharge, does not require immediate assessment.
B. Restlessness in a client with Alzheimer's and bacterial pneumonia could indicate a change in condition, potentially signaling an urgent issue that needs immediate assessment.
C. While pain management is important, the sudden onset of restlessness in a client with cognitive impairment and pneumonia takes priority.
D. An elevated fasting blood glucose level in a newly admitted diabetic client requires attention but might not be as immediately critical as the acute change in behavior seen in option B.
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