Question

The nurse is caring for clients on a medical floor. Which client will the nurse assess first?

a. The client with an AAA who is constipated.
b. The client on bedrest who ambulated to the bathroom.
c. The client with essential HTN who has epistaxis and a headache.
d. The client with arterial occlusive disease who has a decreased pedal pulse.

Answer 1

The nurse will assess the client with essential HTN and epistaxis first, as it may indicate uncontrolled high blood pressure and requires immediate attention.

Step-by-step explanation:

The nurse will assess the client with essential HTN who has epistaxis and a headache first. Epistaxis (nosebleed) can indicate uncontrolled high blood pressure (essential HTN) and may require immediate medical attention. The nurse should prioritize assessing this client to determine the severity of the bleed and provide necessary interventions. Headache can also be a symptom of high blood pressure and needs further evaluation.

The client with an AAA who is constipated, the client on bedrest who ambulated to the bathroom, and the client with arterial occlusive disease who has a decreased pedal pulse also need attention, but their conditions are not presenting immediate life-threatening complications compared to a possible uncontrolled high blood pressure with epistaxis and headache.