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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: IV antibiotics are critical in septic shock to treat the underlying infection, but they take hours to act. Hypotension (80/50 mm Hg) and elevated lactate indicate tissue hypoperfusion, requiring immediate restoration of blood pressure. Vasopressors address shock more rapidly, making antibiotics secondary in the acute stabilization phase.

Choice B reason: Septic shock with blood pressure of 80/50 mm Hg and elevated lactate indicates severe hypoperfusion and tissue hypoxia. Vasopressor therapy, like norepinephrine, restores blood pressure, improving organ perfusion. The ABCDE approach prioritizes circulation, making vasopressors the immediate intervention to prevent organ failure and death in this critical condition.

Choice C reason: Obtaining blood cultures identifies the causative organism in septic shock, guiding antibiotic therapy. However, it does not address immediate hypotension and hypoperfusion, indicated by low blood pressure and high lactate. Vasopressors stabilize circulation first, making cultures a secondary step in the acute management of septic shock.

Choice D reason: IV corticosteroids may be used in refractory septic shock to support adrenal function, but they are not the first-line intervention. Hypotension and elevated lactate require immediate vasopressor therapy to restore perfusion. Corticosteroids are adjunctive and slower-acting, making them less critical than vasopressors in the initial stabilization of septic shock.

A. Pulmonary embolism B. Acute myocardial infarction C. Pericarditis D. Aortic dissection

Correct Answer is B

Explanation

Choice A reason: Pulmonary embolism causes chest pain and diaphoresis but typically presents with tachycardia, dyspnea, and normal or non-specific ECG changes, not ST-segment elevation. The latter is specific to myocardial ischemia, making pulmonary embolism less likely. Embolism affects pulmonary circulation, not coronary arteries, which are implicated in the described ECG findings.

Choice B reason: Acute myocardial infarction presents with chest pain, diaphoresis, and ST-segment elevation on ECG, indicating acute coronary artery occlusion leading to myocardial ischemia. This is a life-threatening emergency requiring immediate intervention like percutaneous coronary intervention. The symptoms and ECG findings align with myocardial infarction, making it the most likely diagnosis.

Choice C reason: Pericarditis causes chest pain, often pleuritic, and may cause diaphoresis, but ECG typically shows diffuse ST-segment elevation, not localized as in myocardial infarction. Pericarditis is less likely to cause acute, severe ischemic symptoms. The specific ST elevation and symptoms point to coronary occlusion, not pericardial inflammation.

Choice D reason: Aortic dissection causes severe, tearing chest pain and may cause diaphoresis, but ECG is usually normal or shows non-specific changes, not ST-segment elevation. Dissection affects the aorta, not coronary arteries, making it less likely. The ECG findings and symptoms strongly suggest myocardial infarction over aortic dissection.

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In an emergency department, a nurse is presented with four clients. Which client should the nurse prioritize based on the ABCDE approach?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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Question 28

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