The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

A 3-year-old child with fever, rash, and sore throat.

A 45-year-old man with chest pain and diaphoresis for 1 hour.

A 14-year-old girl who is crying because she thinks she is pregnant.

A 20-year-old man with a 3-inch shallow laceration on his leg.

Answer and Explanation

The Correct Answer is B

A. A 3-year-old with fever, rash, and sore throat should be evaluated promptly, but these symptoms do not necessarily indicate an immediate life-threatening emergency.
B. A 45-year-old man with chest pain and diaphoresis for 1 hour is the priority because these are classic symptoms of acute coronary syndrome (ACS) or myocardial infarction (MI). Immediate emergency assessment and intervention are required.
C. A 14-year-old girl crying about a possible pregnancy needs emotional support and counseling but does not require immediate emergency intervention.
D. A 20-year-old man with a 3-inch shallow laceration on his leg needs wound care, but his condition is not life-threatening and does not require emergency assessment.

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Correct Answer is B

Explanation

A. Asking what makes the pain better helps determine relief measures but does not specifically address the pattern of occurrence.
B. Asking how long these episodes have been occurring helps identify the pattern of the pain, including its frequency and duration, which is important for diagnosing chronic or recurrent conditions such as migraines or hypertension-related headaches.
C. Asking about other symptoms helps assess associated conditions but does not directly focus on the pattern of the pain.
D. Asking when the pain began helps determine onset but does not provide insight into its recurrence or fluctuation over time.

A. Reassess the blood pressure measurement. B. Notify the provider. C. Recheck the blood pressure measurement in 30 minutes. D. Have the patient care tech take the blood pressure measurement again.

Correct Answer is A

Explanation

A. Reassessing the blood pressure measurement is correct because the nurse should always verify abnormal findings before taking further action. The initial reading could be due to equipment error, improper cuff size, or patient positioning.
B. Notifying the provider is incorrect at this time because the nurse should first confirm the accuracy of the reading before escalating concerns.
C. Rechecking the BP in 30 minutes is incorrect because if the reading is accurate, waiting 30 minutes could delay necessary interventions.
D. Having the patient care tech take the BP again is incorrect because the nurse should personally validate the abnormal finding rather than delegating it.

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The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 40-year-old client is seen at the clinic with a headache and blurred vision that comes and goes. The client reports a pain of a 6 on a scale from 0–10. What question should the nurse ask to obtain more information about the pattern of the pain?

Correct Answer is B

Explanation

The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

Correct Answer is A

Explanation

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