An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first?
Client who describes intense squeezing pressure across the chest.
Client who reports moderate pain that is worse on inspiration.
Client who reports cramping substernal pain.
Client who describes pain as a dull ache.
The Correct Answer is A
A. This description is indicative of possible myocardial infarction (MI), a life-threatening emergency. Immediate evaluation and intervention, such as administering oxygen, obtaining an EKG, and providing pain relief, are crucial to prevent further damage to the heart and reduce mortality.
B. Moderate pain worse on inspiration suggests pleuritic pain, often associated with conditions like pleuritis or pulmonary embolism, which are serious but generally not as immediately life-threatening as an MI.
C. Cramping substernal pain may indicate a gastrointestinal issue, such as gastroesophageal reflux disease (GERD), which is less urgent than a potential MI.
D. A dull ache may be related to musculoskeletal or gastrointestinal issues and does not suggest the immediate need for intervention seen in MI.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A reduction in lump size and pain with oral contraceptives is expected and does not indicate a need to change the treatment plan.
B. Increased lump pain before menstruation is typical for fibrocystic changes and not a cause for concern.
C. Firm, movable lumps in the upper outer breast quadrants are characteristic of fibrocystic changes and do not suggest an alternative condition.
D. An area that is hot, pink, and tender indicates inflammation or possible infection (e.g., mastitis or abscess), requiring further evaluation and potentially altering the treatment plan.
Correct Answer is B
Explanation
A. Bleeding precautions are not required as the issue pertains to neutropenia, not thrombocytopenia.
B. Placing the client in a private room is appropriate as the ANC calculation (WBC × [% neutrophils]) indicates severe neutropenia, increasing the risk of infection.
C. Simply documenting findings does not address the client’s increased infection risk.
D. Blood cultures and antibiotics may be needed later but require additional signs of infection to proceed.
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