The nurse receives report for the day shift. Which client should the nurse assess first?

The client with nephrolithiasis, who has hematuria and is complaining of pain, rates it as a 9 on a 0 to 10 pain scale.

The client with acute post-streptococcal glomerulonephritis who has hematuria with a smoky appearance.

The client with interstitial cystitis who has urinary urgency and pain in the bladder.

The client with Goodpasture syndrome who has pallor, anemia, and renal failure.

Answer and Explanation

The Correct Answer is D

Goodpasture syndrome is a rare, life-threatening autoimmune disorder characterized by the presence of circulating anti-glomerular basement membrane (GBM) antibodies. These antibodies trigger a cytotoxic response that concurrently attacks the alveolar and glomerular basement membranes, leading to pulmonary hemorrhage and rapidly progressive glomerulonephritis. The clinical focus must remain on managing respiratory failure and acute kidney injury to prevent multi-organ collapse.

Rationale:

A. Nephrolithiasis involves the formation of calculi within the urinary tract, causing severe renal colic and microscopic or gross hematuria. While a pain rating of 9 is significant, it represents a non-emergent physiological response to the passage of the stone. This client requires analgesia and hydration but is not at immediate risk of hemodynamic instability or death.

B. Acute post-streptococcal glomerulonephritis (APSGN) is an immune-complex disease that typically presents with smoky-colored urine due to hemolysis of red blood cells. While hematuria and edema are hallmark signs, they are expected manifestations of the inflammatory process following a streptococcal infection. This client is stable and does not take precedence over a client with systemic organ failure.

C. Interstitial cystitis is a chronic inflammatory condition of the bladder wall that causes urinary urgency and suprapubic pain. Although the symptoms are distressing and impact the client's quality of life, they do not constitute an acute emergency. The nurse can manage this client’s discomfort after addressing individuals with potentially fatal complications.

D. Goodpasture syndrome is the priority because it involves alveolar hemorrhage and acute renal failure, which are high-mortality conditions. Pallor and anemia suggest significant internal bleeding, while renal failure indicates a loss of homeostatic regulation. The nurse must assess this client first to monitor for pulmonary compromise and initiate plasmapheresis or immunosuppressive therapy.

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Correct Answer is C

Explanation

Disaster triage utilize the START (Simple Triage and Rapid Treatment) method to prioritize victims based on survivability and resource allocation during mass casualty incidents. The black tag signifies individuals who are deceased or have unsurvivable injuries given the current resource constraints. Categorization focuses on maximizing the greatest good for the greatest number of people by diverting resources toward those with the highest probability of survival.

Rationale:

A. A hard, tender abdomen suggests internal hemorrhage or organ perforation, which is a life-threatening condition requiring immediate surgical intervention. This client is categorized as a red tag (immediate) because they have a high survival probability if treated rapidly. They require urgent transport to a definitive care facility for emergency laparotomy.

B. Crying and the inability to answer questions indicate psychological distress or a minor behavioral reaction without life-threatening physical trauma. This client is categorized as a green tag (minor) or "walking wounded" as their physiological status is stable. They do not require immediate medical resources and can wait for psychological first aid or supportive counseling.

C. Full-thickness burns over 80% of the body represent an expectant category due to the extremely high mortality rate and the intensive resources required for treatment. In a disaster, these individuals are black-tagged to ensure critical resources are not exhausted on unsurvivable cases. Comfort care is provided only after all salvageable victims have been stabilized.

D. A sucking chest wound indicates an open pneumothorax that requires immediate occlusive dressing to prevent respiratory collapse. Although the client is currently alert, this is a red-tag (immediate) injury because it will rapidly progress to tension pneumothorax. Immediate intervention is necessary to maintain pleural integrity and adequate ventilation.

A. "Apply heat to your joints to alleviate pain." B. Use a firm mattress for sleeping." C. "Sleep with a pillow under your knees." D. "Avoid bending your joints to the point where they become painful when exercising." E. "Take tub baths instead of showers."

Correct Answer is ["A","B","D"]

Explanation

Osteoarthritis (OA) is a chronic degenerative joint disorder characterized by cartilage breakdown, synovial inflammation, osteophyte formation, and progressive joint space narrowing, leading to pain, stiffness (especially after inactivity), decreased mobility, and functional impairment primarily in weight-bearing joints such as hips and knees.

Rationale:

A. This is correct because heat therapy promotes vasodilation, reduces joint stiffness, improves synovial fluid viscosity, and decreases pain perception in chronic degenerative joint disease, improving functional mobility in osteoarthritis.

B. This is correct because a firm mattress supports spinal alignment and reduces joint stress during sleep. It helps prevent abnormal joint positioning and minimizes morning stiffness commonly seen in osteoarthritic joints.

C. This is incorrect because placing a pillow under the knees promotes knee flexion contractures, reduces joint extension, and worsens long-term deformity in osteoarthritis, especially in weight-bearing joints already prone to stiffness and limited range of motion.

D. This is correct because avoiding pain-induced joint stress during exercise prevents further cartilage degeneration and inflammation. Exercise should remain within a tolerable range to maintain mobility without exacerbating joint destruction and synovial irritation.

E. This is incorrect because tub baths increase risk of falls, especially in clients with reduced mobility and joint instability. Safer alternatives include showers with assistive devices, as osteoarthritis impairs balance and lower extremity strength.

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The nurse receives report for the day shift. Which client should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The community health nurse is triaging victims at the disaster site. Which client should the nurse categorize as a black tag?

Correct Answer is C

Explanation

A nurse is teaching a client who has osteoarthritis of the hip and knee about self-management of the disease. Which statements should the nurse include in the teaching? Select All That Apply.

Correct Answer is ["A","B","D"]

Explanation

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