The nurse is caring for clients on a medical floor. Which client should be assessed first?
The hemodialysis client who is experiencing anuria
The client diagnosed with cirrhosis who is complaining of itching
The client diagnosed with peripheral arterial disease who is complaining of pain when walking
The client diagnosed with lupus who is complaining of chest pain
The Correct Answer is D
Choice A reason: Anuria in hemodialysis is expected due to renal failure; it’s not acute unless accompanied by distress, less urgent than chest pain’s potential severity.
Choice B reason: Itching in cirrhosis from bile salts is uncomfortable but not life-threatening, ranking below chest pain, which could indicate critical cardiac or pulmonary issues.
Choice C reason: Pain when walking in PAD (claudication) is chronic and stable, not an immediate threat compared to chest pain, which requires urgent evaluation.
Choice D reason: Chest pain in lupus may signal pericarditis or pleuritis, potentially life-threatening complications, prioritizing assessment for rapid intervention over stable conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Butterfly rash, a malar erythema, is a classic SLE sign, triggered by photosensitivity and immune complex deposition in skin, reflecting systemic inflammation.
Choice B reason: Pleural effusions occur in SLE from serositis, where autoantibodies inflame pleura, causing fluid buildup, a common thoracic manifestation of the disease.
Choice C reason: Elevated ammonia levels relate to liver failure, not SLE, which affects kidneys and joints, not ammonia metabolism, making this unrelated.
Choice D reason: Pericarditis in SLE results from immune-mediated inflammation of the pericardium, causing chest pain and effusion, a frequent cardiac feature.
Choice E reason: Esophageal varices stem from portal hypertension in cirrhosis, not SLE, which targets connective tissues, not liver vasculature directly.
Correct Answer is C
Explanation
Choice A reason: Crackles indicate pulmonary edema from left-sided heart failure, where fluid backs up into lungs, not right-sided failure, which affects systemic circulation instead.
Choice B reason: Orthopnea, dyspnea when lying flat, results from left-sided failure’s pulmonary congestion, not right-sided failure, which causes systemic venous pooling, not lung issues.
Choice C reason: Jugular venous distention occurs in right-sided heart failure as the right ventricle fails, backing blood into veins, elevating neck vein pressure visibly.
Choice D reason: Blood-tinged sputum suggests pulmonary edema or infarction, tied to left-sided failure or embolism, not right-sided failure’s systemic congestion pattern.
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