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 B
Explanation
A) Describe the surgery and what the client will experience postoperatively:
While it is essential to provide information about the surgery and the postoperative experience, the primary focus of preoperative teaching is to ensure that the client understands the information provided. This option does not specifically address the client's level of understanding, which is crucial for effective teaching.
B) Reinforce information at the client's level of understanding:
This is the correct choice. When contributing to the preoperative teaching plan, the nurse should ensure that information is provided in a way that the client can comprehend. Reinforcing information at the client's level of understanding enhances communication and ensures that the client is well-informed about the procedure and what to expect.
C) Reassure the client that the surgery rarely has any negative outcomes:
While it is important to provide reassurance and support to the client, it is not appropriate to make promises or provide guarantees about the outcome of the surgery. Surgery, by its nature, carries risks, and it is essential to provide the client with accurate information while maintaining a supportive and empathetic approach.
D) Notify the client's family of the plan of care:
While it is important to involve the client's family in the plan of care, the primary focus of preoperative teaching is on the client. Involving the family in the plan of care is important, but it is not the most immediate action in the context of preoperative teaching.
Correct Answer is C
Explanation
(A) Kernig’s sign: Kernig’s sign is a clinical sign in which severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees. It is commonly associated with meningitis, not hypocalcemia.
(B) Brudzinski’s sign: Brudzinski’s sign is a symptom of meningitis. It is not associated with hypocalcemia.
(C) Chvostek’s sign: This is the most appropriate answer. Chvostek’s sign is a clinical sign of existing nerve hyperexcitability (tetany) seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve.
(D) Cullen’s sign: Cullen’s sign is a medical term referring to superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is not associated with hypocalcemia.
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