The nurse is caring for a group of patients. Which of the the following patients should the nurse evaluate first?
A patient with coronary artery disease (CAD) who reports chest pain radiating to the jaw.
A patient with venous insufficiency with 2+ pitting edema.
A patient receiving enoxaparin (Lovenox) for experiencing an MI 3 days ago.
A patient with peripheral artery disease (PAD) with a diminished pulse.
The Correct Answer is A
A. A patient with coronary artery disease (CAD) who reports chest pain radiating to the jaw: This patient should be evaluated first. Chest pain radiating to the jaw can be a sign of a heart attack, which is a life-threatening condition. Immediate medical attention is required to prevent further damage to the heart muscle.
B. A patient with venous insufficiency with 2+ pitting edema: While this patient’s condition needs to be addressed, it is not as immediately life-threatening as a potential heart attack. Venous insufficiency and edema can lead to discomfort and complications if left untreated, but these complications are typically not immediate.
C. A patient receiving enoxaparin (Lovenox) for experiencing an MI 3 days ago: This patient is already receiving treatment for their condition. While they should be monitored for side effects of the medication and signs of further cardiac issues, they are not the highest priority based on the information given.
D. A patient with peripheral artery disease (PAD) with a diminished pulse: While a diminished pulse can indicate poor blood flow, which can lead to complications such as tissue damage and non-healing wounds, it is not as immediately life-threatening as a potential heart attack. This patient should be evaluated, but they are not the highest priority based on the information given.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
(A) “I promise I won’t tell anyone about this.”: This statement is inappropriate because it is the nurse’s legal and ethical duty to report any suspicion or evidence of child abuse to the appropriate authorities. Keeping the information confidential could potentially endanger the child.
(B) “Let’s discuss what you have told me with your family members.”: This statement could potentially put the child at further risk, especially if the abuser is a family member. The child’s safety is the primary concern, and discussing the abuse with family members without the involvement of child protective services could be harmful.
(c) “Your family is bad for doing this to you.”: This statement is judgmental and unprofessional. It’s important to maintain a neutral stance and focus on the child’s feelings and safety rather than placing blame.
(D) “It is not your fault that this happened.”: This is the most appropriate response. It’s crucial to reassure the child that they are not to blame for the abuse. This can help alleviate feelings of guilt or shame that the child may be experiencing. The nurse should also take steps to ensure the child’s immediate safety and report the abuse to the appropriate authorities.
Correct Answer is ["A","D"]
Explanation
A. Review strategies to reduce sodium intake:
This educational method involves providing information and teaching the client specific strategies to reduce sodium intake, such as reading food labels, avoiding high-sodium processed foods, and choosing fresh fruits and vegetables. It engages the cognitive domain of learning as it focuses on acquiring knowledge and understanding of the topic.
B. Ask the client how they are feeling about starting a low sodium diet:
This educational method involves exploring the client's feelings and emotions regarding the low sodium diet. It primarily engages the affective domain of learning, which focuses on attitudes, beliefs, and feelings.
C. Observe the client choose low sodium foods:
This educational method involves observing the client's behavior and actions. It primarily engages the psychomotor domain of learning, which focuses on physical skills and actions.
D. Discuss the physiology of hypertension with the client:
This educational method involves explaining the underlying physiology of hypertension, including factors such as sodium intake, blood pressure regulation, and cardiovascular health. It engages the cognitive domain of learning as it focuses on acquiring knowledge and understanding of the physiological processes involved in hypertension.
E. Encourage the client to share their thoughts in a support group:
This educational method involves providing opportunities for the client to share their thoughts and experiences with others in a support group setting. It primarily engages the affective domain of learning, which focuses on attitudes, beliefs, and feelings.
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