a nurse working in the emergency department is assessing several clients which of the following clients is the highest priority
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Leadership and Management HESI Quizlet

1. A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?

Correct answer: D

Rationale: The correct answer is D because shortness of breath with referred pain may indicate a serious condition, such as a cardiac event or pulmonary embolism, making this the highest priority. Option A, flank pain with diaphoresis, could suggest kidney-related issues but is not as immediately life-threatening as compromised breathing. Option B, active bleeding, though serious, can usually be controlled with proper interventions. Option C, a raised red skin rash, may indicate an allergic reaction but is not as urgent as respiratory distress with neck and shoulder pain.

2. A clinical instructor teaches a class for the public about diabetes mellitus. Which individual does the nurse assess as being at highest risk for developing diabetes?

Correct answer: C

Rationale: The 42-year-old client who is 50 pounds overweight is at the highest risk for developing diabetes. Excess weight is a significant risk factor for diabetes as it can lead to insulin resistance and metabolic abnormalities. Choices A, B, and D are also risk factors for diabetes, but being overweight has a stronger association with the development of the condition compared to lack of exercise, excessive alcohol consumption, or smoking.

3. The wound irrigation process cleanses the wound and:

Correct answer: D

Rationale: The correct answer is D because wound irrigation allows for the introduction of medications in solution form to the wound site. Choice A is incorrect because while wound irrigation can help with pain management indirectly by promoting healing, its primary purpose is not to reduce pain directly. Choice B is incorrect as wound irrigation primarily aims to cleanse the wound and remove contaminants rather than creating a 'clean' area to stop infection spread. Choice C is incorrect because wound irrigation does not involve pushing extravasated blood from a hematoma into nearby healthy tissue; its main goal is to cleanse the wound and promote healing.

4. Which patient is at greatest risk for papilledema?

Correct answer: D

Rationale: An adolescent with a closed head injury is at the highest risk for papilledema due to increased intracranial pressure. Papilledema is often a consequence of elevated intracranial pressure, which can occur in conditions like head trauma. Choices A, B, and C do not directly correlate with an increased risk of papilledema compared to a closed head injury, which is more likely to lead to elevated intracranial pressure and subsequent papilledema.

5. Most water leaves the body by way of the:

Correct answer: D

Rationale: Most water leaves the body through the kidneys. The kidneys play a crucial role in filtering waste and excess substances from the blood to form urine, which is then excreted out of the body. Choices A, B, and C are incorrect because while a small amount of water can be lost through respiration, feces, and sweating, the primary organ responsible for regulating water balance and excretion is the kidneys.

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