Which client admitted to the emergency department should the nurse see first?

A client with a blood pressure of 170/95 mm Hg

A client experiencing a "ripping" sensation in the chest.

A client taking anticoagulants with bloody stool.

A client with a urine output of 240 mL in 12 hours.

Answer and Explanation

The Correct Answer is B

Rationale:

A. While this indicates hypertension, it is not immediately life-threatening unless accompanied by other symptoms such as chest pain, shortness of breath, or neurological changes. This client requires assessment and possible intervention but is not the highest priority.

B. A “ripping” or tearing chest pain is highly suggestive of an aortic dissection, a life-threatening emergency. This condition can rapidly lead to aortic rupture, cardiac tamponade, or death. According to the ABC and Maslow priority frameworks, this client requires immediate assessment and intervention, making them the highest priority.

C. This indicates gastrointestinal bleeding, which can be serious, especially in patients on anticoagulants, but the client is likely hemodynamically stable if vital signs are not provided. While urgent, it is not more immediately life-threatening than a suspected aortic dissection.

D. This is oliguria and may indicate early renal compromise, but it is not an immediate threat to life compared to suspected aortic dissection. This client should be assessed promptly but after addressing the highest-risk patientTop of FormBottom of Form

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Correct Answer is B

Explanation

Rationale:

A. The standard physical assessment sequence is usually inspection, auscultation, percussion, and palpation, not beginning with auscultation before inspection. Following the wrong sequence may lead to inaccurate assessment findings.

B. In clients with cirrhosis and possible abdominal complications (e.g., ascites, tenderness), the abdominal assessment should begin with inspection, followed by auscultation before palpation and percussion. Palpation or percussion before auscultation can stimulate bowel activity and give false bowel sound readings. Since this client is also confused, careful auscultation first ensures accurate assessment while minimizing discomfort or distress.

C. Palpation should begin away from painful areas to avoid causing guarding or spasm that can interfere with assessment. Starting with the most painful areas can increase patient discomfort and make it difficult to accurately assess abdominal findings.

D. While inspection is first, auscultation should be performed before palpation and percussion to obtain accurate bowel sounds. Simply ending with palpation without auscultation first does not follow best-practice assessment protocols.

A. Diarrhea B. Presence of a pressure ulcer C. Kinked urinary catheter tubing D. Fecal impaction E. Respiratory congestion

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

Explanation

Rationale:

A. While diarrhea is a gastrointestinal symptom, it is not a common trigger for autonomic dysreflexia (AD). AD is usually precipitated by a noxious stimulus below the level of spinal cord injury, typically related to bladder or bowel distention or skin irritation.

B. Pressure ulcers create a painful or noxious stimulus below the level of injury, which can trigger autonomic dysreflexia. The body responds with sudden sympathetic overactivity, causing hypertension, headache, sweating, and flushing above the level of injury.

C. A blocked or kinked urinary catheter causes bladder distention, the most common trigger for AD. The distention sends afferent signals to the spinal cord, resulting in uncontrolled sympathetic responses. Immediate catheter assessment and correction are critical to resolve the episode.

D. Bowel distention from fecal impaction is a frequent cause of AD. Like bladder distention, it provides a noxious stimulus below the injury level, triggering hypertension, bradycardia, headache, and sweating. Prompt removal of the impaction alleviates the dysreflexic episode.

E. While respiratory issues are important to monitor, they are not a typical trigger for autonomic dysreflexia. AD is usually initiated by stimuli below the level of the spinal cord injury, particularly involving the bladder, bowel, or skin.

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Which client admitted to the emergency department should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client presents to the emergency department because he is coughing up blood. His wife reports that the client has cirrhosis of the liver and increased confusion. How should the nurse perform an abdominal assessment?

Correct Answer is B

Explanation

A client with a TS spinal cord injury has manifestations of autonomic dysreflexia. Which assessments would indicate a possible cause for this condition? Select all that apply.

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

Explanation

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