The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first?
A client diagnosed with chronic obstructive pulmonary disease (COPD) who is short of breath.
An immobile client with a stage 3 pressure ulcer on the coccyx who is having low back pain.
A client with congestive heart failure who reports a 3-pound weight gain in the last two days.
A terminally ill older adult who has refused to eat or drink anything for the last 48 hours.
The Correct Answer is A
Choice A reason: Shortness of breath in a client with COPD may indicate acute respiratory distress, infection, or exacerbation. This is a potentially life-threatening condition requiring immediate assessment and intervention to prevent hypoxia or respiratory failure. Prioritizing this client aligns with airway-first principles in triage.
Choice B reason: A stage 3 pressure ulcer with pain is concerning but not immediately life-threatening. It requires wound care and pain management, but the condition is stable enough to be addressed after more urgent cases.
Choice C reason: A 3-pound weight gain in congestive heart failure may signal fluid retention and worsening heart failure. While important, it is not as immediately critical as respiratory compromise in COPD.
Choice D reason: Refusal to eat or drink in a terminally ill client may reflect end-of-life progression. While this warrants compassionate care and monitoring, it is not an acute emergency compared to respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Knowing the frequency of incomes above and below the average helps the nurse understand income distribution and identify disparities. Averages can be misleading if skewed by outliers. For example, a few high-income families can raise the average while most families earn far less. This insight is crucial for targeting interventions to those most in need.
Choice B reason: Focusing on college-educated individuals assumes a level of education that may not be representative of the entire community. Without knowing the educational distribution, this approach could exclude vulnerable populations.
Choice C reason: Questioning the reliability of the average income may be relevant for data validation but does not guide intervention planning. The nurse’s role is to use available data to assess needs, not audit its accuracy.
Choice D reason: Studying upper-middle-class families may provide sociological insights but does not help identify or address health disparities. The nurse should prioritize understanding the needs of lower-income or underserved groups.
Correct Answer is D
Explanation
Choice A reason: While understanding the living conditions may help assess crowding and potential environmental risks, it does not directly address the acute symptoms the client is experiencing. It is a secondary concern compared to identifying a toxic exposure.
Choice B reason: Work hours and rest breaks are relevant for assessing heat exhaustion or fatigue, but they do not explain the constellation of symptoms including abdominal cramps and respiratory difficulty. These symptoms suggest a toxicological cause.
Choice C reason: Lead exposure can cause neurological and gastrointestinal symptoms, but it typically presents with chronic issues rather than acute respiratory distress. The symptoms described are more consistent with pesticide toxicity, which is common among agricultural workers.
Choice D reason: Pesticide exposure is a high-priority concern in migrant farm workers due to frequent contact with chemicals. The symptoms—dizziness, headaches, abdominal cramps, and difficulty breathing—are hallmark signs of organophosphate or carbamate poisoning. Immediate assessment and intervention are critical.
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