The following clients are waiting to be seen in the emergency department. Which client should the nurse assess first?
Cocaine abuser with chest pain
An intoxicated client with a long history of alcoholism
A client who recently experienced a “bad trip” from LSD
A young man who thinks they have been given flunitrazepam (Rohypnol)
The Correct Answer is A
A: A cocaine abuser with chest pain should be assessed first because chest pain can indicate a life-threatening condition such as a myocardial infarction (heart attack). Cocaine use increases the risk of cardiovascular events, making this client a priority.
B: An intoxicated client with a long history of alcoholism needs medical attention, but their condition is likely less immediately life-threatening compared to chest pain from cocaine use.
C: A client who recently experienced a “bad trip” from LSD may be experiencing psychological distress, but this is generally not as immediately life-threatening as chest pain.
D: A young man who thinks they have been given flunitrazepam (Rohypnol) needs to be assessed for potential drug-facilitated assault, but this situation is less immediately critical than chest pain from cocaine use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Using seclusion should be a last resort and only used when the patient poses an immediate threat to themselves or others. It is not a proactive strategy for managing frustration.
B: Ensuring the patient understands harsh consequences for violent episodes may not be effective in preventing aggression and can increase feelings of frustration and resentment.
C: Responding to emotional outbursts with negative reinforcement can escalate the situation and is not a therapeutic approach.
D: Creating a quiet and relaxing room provides a safe space for the patient to calm down and manage their emotions. This proactive strategy helps prevent escalation and supports the patient’s ability to cope with frustration
Correct Answer is D
Explanation
A: Having the patient eat meals in private is not recommended as it can facilitate purging behaviors without supervision.
B: Educating the patient on the long-term complications of purging is important but not the primary intervention to prevent immediate purging behavior.
C: Weighing the patient at the same time every morning is a standard practice in managing eating disorders but does not directly address the purging behavior.
D: Monitoring the patient during and after meal times is crucial to prevent purging and ensure the patient is following the treatment plan.
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