The nurse is evaluating a transgender female client in the emergency department who is taking estrogen therapy. Which of the following assessment findings would be of priority concern for the nurse?
Client reports having intermittent mild headaches.
Client reports some erectile dysfunction.
Client reports having dyspnea and chest pain.
Client reports having elevated liver function tests.
The Correct Answer is C
Choice A reason: Intermittent mild headaches can be a side effect of estrogen therapy, but they are generally not life-threatening. While they should be monitored and managed, they do not constitute an immediate priority compared to more severe symptoms.
Choice B reason: Erectile dysfunction is a common side effect of estrogen therapy in transgender females. Although it can affect quality of life, it is not an urgent medical concern and does not require immediate intervention.
Choice C reason: Dyspnea (difficulty breathing) and chest pain are potentially serious symptoms that could indicate cardiovascular issues, including pulmonary embolism, which is a known risk associated with estrogen therapy. These symptoms require immediate attention and intervention to rule out life-threatening conditions.
Choice D reason: Elevated liver function tests can occur with estrogen therapy and should be monitored over time. However, while they indicate a need for further investigation and possible adjustment of therapy, they are not as immediately critical as symptoms of dyspnea and chest pain.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: The red category in START triage is reserved for clients who need immediate intervention to survive. This includes those with life-threatening injuries such as severe bleeding or airway obstruction. In this scenario, the 10-year-old client is awake, alert, and ambulatory, indicating that their condition is not immediately life-threatening. Therefore, the red category is not applicable.
Choice B reason: The green category is used for clients who are able to walk and have minor injuries. While the 10-year-old client is ambulatory, the presence of a headache and neck pain suggests that their injuries might be more severe than minor. The green category would not be appropriate because their symptoms indicate a need for further evaluation and monitoring.
Choice C reason: The black category is assigned to clients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. The 10-year-old client is awake, alert, and able to walk, which clearly does not align with the criteria for the black category. Therefore, this category is not suitable for the client's condition.
Choice D reason: The yellow category in START triage is for clients who require medical attention but their injuries are not immediately life-threatening. Given that the 10-year-old client is reporting a headache and neck pain, there is a potential risk of underlying injury that warrants attention but does not require immediate intervention. Thus, the yellow category is the most appropriate acuity level for this client.
Correct Answer is B
Explanation
Choice A reason: Providing a centralized area for stocking the needed supplies is important for logistical reasons, ensuring that all necessary materials are readily available. However, this is not the primary scientific rationale for designating a specific decontamination area. The primary focus is on preventing contamination and ensuring safety.
Choice B reason: Preventing secondary contamination to health-care providers is the most crucial reason for designating a specific area for decontamination. This measure is vital to avoid spreading hazardous substances to others and ensuring the safety and effectiveness of the decontamination process. By containing the contamination in a controlled area, health-care providers can minimize the risk of exposure and cross-contamination.
Choice C reason: Designating an area where bioterrorism clients can receive care is important, but it is not the primary rationale for having a specific decontamination area. While care and treatment are critical, the main goal of the decontamination area is to remove contaminants and protect health-care providers and other patients from exposure.
Choice D reason: Providing showers and privacy to the client in the decontamination area is beneficial for the comfort and dignity of the client. However, this is not the main scientific rationale for having a designated decontamination area. The primary reason is to control and contain contamination and prevent it from spreading.
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