Nokea
Four clients present to the emergency department. The nurse should plan to see which of the following clients first?
- A. A 6-year-old client with a dislocated shoulder
- B. A 26-year-old client with sickle cell disease and severe joint pain
- C. A 76-year-old client who is confused, febrile, and has foul-smelling urine
- D. A 50-year-old client who has slurred speech and reports a headache
Correct Answer: D
Rationale: The correct answer is D. The client with slurred speech and a headache may be experiencing a stroke, which is a medical emergency that requires immediate attention to prevent irreversible brain damage. While each client requires prompt assessment and care, the priority is to address potentially life-threatening conditions first. Choices A, B, and C, although important, do not present with symptoms as critical as those of a possible stroke, which necessitates urgent intervention.
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A charge nurse is discussing the use of applying ice to a client's injured knee with a newly licensed nurse. Which of the following is a benefit of this treatment?
- A. Systemic analgesic effect
- B. Increase in metabolism
- C. Decreased capillary permeability
- D. Vasodilation
Correct Answer: C
Rationale: The correct answer is C: Decreased capillary permeability. Ice application helps decrease capillary permeability, which in turn reduces swelling and inflammation at the injury site. This vasoconstriction effect helps to limit the extent of the injury. Choices A, B, and D are incorrect. Applying ice locally does not produce a systemic analgesic effect but rather a localized numbing effect. It does not increase metabolism but rather slows down metabolic processes in the affected area. Additionally, ice application causes vasoconstriction, not vasodilation.
A client receiving IV moderate (conscious) sedation with midazolam has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse?
- A. Place the client in a prone position
- B. Implement positive pressure ventilation
- C. Perform nasopharyngeal suctioning
- D. Administer flumazenil
Correct Answer: D
Rationale: In this scenario, the client is showing signs of respiratory depression and central nervous system depression due to midazolam sedation. Administering flumazenil is the correct action as it is the antidote for midazolam, a benzodiazepine, and can reverse the sedative effects to restore respiratory function. Placing the client in a prone position (choice A) may worsen respiratory compromise. Implementing positive pressure ventilation (choice B) is not the first-line intervention for sedation-related respiratory depression. Performing nasopharyngeal suctioning (choice C) is not indicated as there are no signs of airway obstruction requiring suctioning.
A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the following statement: "When the cat's away, the mice will play." The client responds, "The mice come out when the cat is not around." The nurse should document this finding as:
- A. Echolalia
- B. Associative looseness
- C. Neologisms
- D. Concrete thinking
Correct Answer: D
Rationale: The client's literal interpretation of the statement is an example of concrete thinking, a cognitive symptom often seen in schizophrenia where abstract thinking is impaired. Choice A, Echolalia, is the repetition of words spoken by others, which is not demonstrated in this scenario. Choice B, Associative looseness, refers to a disturbance in the logical progression of thoughts, leading to a disorganized thought process. Choice C, Neologisms, involves creating new words or phrases with unique meanings, which is not evident in the client's response.
A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?
- A. Apply skin preparation to wound edges
- B. Cleanse the wound with normal saline
- C. Don sterile gloves
- D. Determine the client's pain level
Correct Answer: D
Rationale: The correct answer is to determine the client's pain level first. Assessing the client's pain is crucial before proceeding with any procedure, including dressing changes. This step ensures that appropriate pain management measures can be implemented, making the wound care process as comfortable as possible for the patient. Applying skin preparation to wound edges (choice A) can come after addressing the pain. While cleansing the wound with normal saline (choice B) and donning sterile gloves (choice C) are important steps in wound care, they should follow the assessment of the client's pain level to prioritize the patient's comfort and well-being.
A nurse is assessing a client who was brought to the psychiatric emergency services by law enforcement. The client has disorganized, incoherent speech with loose associations and religious content. The nurse should recognize these signs and symptoms as consistent with which of the following?
- A. Alzheimer's disease
- B. Schizophrenia
- C. Substance intoxication
- D. Depression
Correct Answer: B
Rationale: The correct answer is B: Schizophrenia. Disorganized speech, loose associations, and religious delusions are characteristic symptoms of schizophrenia. In this scenario, the client's presentation aligns with positive symptoms of schizophrenia, indicating a severe mental disorder requiring immediate attention. Choice A, Alzheimer's disease, primarily involves cognitive decline and memory impairment, not disorganized speech or religious content. Choice C, Substance intoxication, may present with altered mental status but typically lacks the persistent pattern of symptoms seen in schizophrenia. Choice D, Depression, is associated with a different set of symptoms such as low mood, anhedonia, and changes in appetite or sleep, rather than disorganized speech and loose associations.