In an emergency department, a nurse is presented with four clients. Which client should the nurse prioritize based on the ABCDE approach?
A 40-year-old with a headache following a stressful day at work
A 30-year-old with a minor laceration on the arm
A 50-year-old with suspected sepsis displaying altered mental status
A 25-year-old with a sprained ankle
The Correct Answer is C
Choice A reason: A headache following a stressful day suggests a tension headache, which is typically benign and not life-threatening. The ABCDE approach prioritizes airway, breathing, circulation, disability, and exposure, focusing on immediate threats. A headache does not compromise these critical systems acutely, making it a lower priority compared to conditions affecting vital functions like sepsis.
Choice B reason: A minor laceration on the arm is a superficial injury that may cause bleeding but is unlikely to be life-threatening unless uncontrolled or infected. The ABCDE approach would assess for significant hemorrhage under circulation, but a minor laceration typically does not impair airway, breathing, or neurological status, placing it lower in priority than sepsis with altered mental status.
Choice C reason: Suspected sepsis with altered mental status is a medical emergency. Sepsis involves systemic infection leading to organ dysfunction, with altered mental status indicating neurological compromise (disability in ABCDE). This suggests possible cerebral hypoperfusion or septic encephalopathy, requiring urgent intervention to stabilize circulation and prevent multi-organ failure, making this the highest priority.
Choice D reason: A sprained ankle is a musculoskeletal injury causing pain and swelling but does not typically affect airway, breathing, circulation, or neurological status in the ABCDE framework. It is a stable condition requiring supportive care like rest and ice, not immediate intervention, making it a lower priority compared to life-threatening conditions like sepsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Full-thickness burns destroy all skin layers, leading to scar tissue formation. Without joint alignment and mobility, scar tissue can tighten, causing contractures that limit movement. Maintaining joint alignment through positioning and therapy prevents these deformities, preserving function and reducing the risk of permanent joint immobility in burn recovery.
Choice B reason: Wound breakdown occurs due to infection or poor healing in burns but is not directly related to joint alignment. Maintaining alignment prevents contractures, not wound integrity issues. Wound breakdown is managed with infection control and dressings, making this complication unrelated to the goal of joint positioning.
Choice C reason: Heterotopic ossification involves abnormal bone growth in soft tissues, sometimes seen in severe burns, but it is not prevented by joint alignment. It results from prolonged immobility or trauma, not directly from burn scarring. Joint alignment targets contractures, making this an incorrect complication for the stated goal.
Choice D reason: Neuropathy in burns may result from nerve damage or compression but is not primarily prevented by joint alignment. Maintaining alignment focuses on preventing scar tissue contractures, not neurological complications. Neuropathy management involves pain control and monitoring, not positioning, making this unrelated to the care plan’s goal.
Correct Answer is D
Explanation
Choice A reason: Discomfort during dialysate inflow is common in peritoneal dialysis due to the rapid introduction of fluid into the peritoneal cavity, stretching the peritoneum. It is usually transient and not a sign of serious complications like infection. Immediate reporting is unnecessary unless severe or persistent, as it does not indicate an acute emergency.
Choice B reason: Slight abdominal pressure during peritoneal dialysis is normal due to the presence of dialysate in the peritoneal cavity. It does not indicate a serious complication like infection or peritonitis. This sensation typically resolves and does not require immediate reporting unless accompanied by severe pain or other alarming symptoms.
Choice C reason: Yellow dialysate outflow is typically normal, as dialysate may appear slightly yellow due to the presence of fibrin or minor hemolysis. It does not indicate infection or a life-threatening issue. Clear or slightly yellow outflow is expected, unlike purulent outflow, which signals infection and requires urgent attention.
Choice D reason: Purulent dialysate outflow indicates peritonitis, a serious complication of peritoneal dialysis caused by bacterial infection in the peritoneal cavity. This presents with cloudy, pus-filled effluent, often with fever or abdominal pain. Immediate reporting is critical to initiate antibiotics and prevent sepsis, making this the most urgent finding to address.
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