An emergency department nurse triages clients who present with discomfort. Which client would the nurse plan to assess first?
Client who reports cramping substantial pain.
Client who reports moderate pain that is worse on inspiration.
Client who describes pain as dull ache.
Client who describes intense squeezing pressure across the chest
The Correct Answer is D
A. Client who reports cramping substantial pain: Cramping can indicate gastrointestinal or menstrual issues, which are rarely immediately life-threatening. Assessment is important but not the highest priority.
B. Client who reports moderate pain that is worse on inspiration: Pain with inspiration may suggest pleuritic pain or mild respiratory involvement, which requires assessment but is not as urgent as signs of possible cardiac events.
C. Client who describes pain as dull ache: Dull aching pain is typically non-urgent and often related to musculoskeletal or chronic conditions. Immediate triage priority is lower compared to acute, potentially life-threatening symptoms.
D. Client who describes intense squeezing pressure across the chest: This presentation is characteristic of myocardial infarction or acute coronary syndrome. Rapid assessment and intervention are critical to prevent cardiac damage or death, making this client the highest priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Perform immediate defibrillation: Defibrillation is indicated for pulseless ventricular tachycardia or ventricular fibrillation. Since this client has a pulse and is hemodynamically stable, defibrillation is not appropriate.
B. Administer adenosine 6 mg IVP: Adenosine is the first-line treatment for stable SVT. Administering a rapid IV push of 6 mg is the initial step per hospital dysrhythmia protocols to terminate the arrhythmia safely while the client remains stable.
C. Perform immediate cardioversion: Synchronized cardioversion is reserved for clients with SVT who are unstable (e.g., hypotension, chest pain, altered mental status). This client is stable, so cardioversion is not the first action.
D. Administer adenosine 12 mg IVP: A 12 mg dose of adenosine is used only if the initial 6 mg dose is ineffective. The protocol starts with 6 mg first, making 12 mg premature as the initial intervention.
Correct Answer is A
Explanation
A. “This condition is caused by the coronary arteries spasming, not by cholesterol.”: Providing accurate, factual information about Prinzmetal angina addresses the client’s confusion and anxiety. Explaining that the condition is due to coronary artery spasm, rather than atherosclerotic plaque, helps correct misconceptions and empowers the client.
B. “Just because you’re young and eat right doesn’t mean you can’t have plaque buildup.”: Prinzmetal angina is not caused by plaque buildup. It may increase anxiety and confusion rather than providing helpful education.
C. “I understand it can be upsetting to have coronary artery disease at your age.”: While empathetic, this statement reinforces a misunderstanding. The client does not have typical coronary artery disease from plaque; education about the actual condition is appropriate.
D. “I am sure everything will be alright.”: Providing reassurance without education does not address the client’s concern or correct her misconceptions. It may minimize her feelings and fail to provide necessary understanding of the condition.
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