Hi. I'm Professor Lawes and in this portion of our video series
we're going to look at the NCLEX questions called TRENDS.
Now, this one is a special one because it's prioritization of care.
So let's get started. First, here's our format.
We're going to kind of give you a feel of what the environment would look like
because I always want to encourage you to picture what's going on in your mind.
It will focus your brain and help you raise your scores.
So, 4 clients, not surprising.
When it's a prioritization question,
there is going to be 4 clients.
So 4 clients presented to the emergency
department at about the same time on Tuesday.
The triage nurse obtains the medical
histories and all 4 are admitted.
Okay, not surprising, but we know where we
are, emergency room, all 4 have been admitted.
And now we're going to take
a look at their histories.
Client one, now remember this has nothing to do
with priority, these are just randomly assigned.
We'll have to figure out which one is the
most unstable, who needs the most care first.
All of these patients will be seen, all
of these patients deserve to be seen,
but your job as someone taking the NCLEX is to identify
who's the most unstable requiring the most immediate care.
So you see the time up there,
it says Tuesday 08:00 to 08:30.
Client 1, a 37-year-old client who sustained a motor
vehicle accident yesterday. Okay. So, what do we know?
Their age, we know what happened to them, they had a
motor vehicle accident, and it happened yesterday.
Now the client has no visible injuries on the body other than
some abdominal bruising and pain, but reports feeling weak.
Before you go on to client 2, think about what's the worst case scenario
for somebody who has had a trauma like a motor vehicle accident.
What's the worst possible case scenario? Is
there any abnormal assessment in this question?
Abdominal bruising is a little weird. Right? That's not normal.
And what could that possibly indicate?
The other thing is the patient reports feeling weak.
Now that's all we have to go on.
Accident yesterday. The patient has some abnormal feelings
of feeling weak and they've got abdominal bruising and pain.
Now, let's compare client 1 to client 2.
Who's more unstable?
Well, client 2 is an 82-year-old client. Oohhh, I was getting a little
more worried about the elderly. They've got suspected food poisoning.
Now they vomited 4 times today. We know that's not
normal and likely to cause him to be dehydrated.
Family reports that the client seems confused.
Well, they're elderly and they're dehydrated.
That would kind of check, that would kind of
follow along that they would be confused.
So, between 1 and 2, who do I think is more at risk? You know what?
I'm not really sure. And sometimes that's going to happen to you.
So let's say for now we're going to keep 1 and 2 in
because we can't really make a straight up call yet.
So I don't want that to throw you. You can come back to it and that's just a
normal part of the process when you're taking a tough test like the NCLEX.
So let's look at client number 3. Okay don't panic, don't think
bad things about yourself or you're never going to pass the test.
Just say "Uhh I'm not really sure right now. I'm going
to go on to the next client and then I'll come back.
6-month-old infant with increased drooling
and rash on the lip and chin area.
The mother states that the infant
has been more irritable than usual.
Or whether you have your own children or you've been around
children, 6 months old children are usually cutting teeth. Right?
And when they cut their teeth, they drool everywhere and
they can get kind of irritated and that would be normal.
So, client 3 is definitely not more unstable than client 2 or client
1 at this point. So I'm just kind of getting a lay on the land.
Client 4, okay this is a 60-year-old client who had a cholecystectomy
6 days ago and reports severe pain at the surgical site.
Alright, 60 years old, it's kind of around the border there, had a
cholecystectomy (that's removal of the gall bladder) 6 days ago.
Is it normal that they would be reporting
severe pain at the surgical site? No.
So see, this first time through I don't have
near enough information to make a call.
The only one I kind of have a suspicion about is like "Hhmmm, client 3
is probably just normal, typical, teething kid and mom brought them in."
But let's keep moving through the question
to make sure we haven't missed something.
Okay, client 1. Whoah,
update, 10 o'clock.
Remember we were at 8:00 to 08:30, now we're at 10 am and that's
what you'll see is a flow of information in the question.
Client 1 has developed abdominal distension and dizziness.
Remember what happened to this client.
They had an MVA, they could've experienced some
trauma, we had some weird bruising. Right?
Some abdominal bruising. Now their abdomen is
distended and they feel not just weak, but dizzy.
Client 2, ohh the client has vomited 2 more
times and is really not oriented to place now.
So, that dehydration is probably growing worse by this point.
Client 3, oh they feel very warm to touch.
So, fever could mean infection but with the other signs,
uhhmm I'm thinking that could be just cutting teeth.
Number 4, oohhh, okay that's kind of gross. The
surgical site exhibits a yellowish purulent discharge.
Well, that's not a good sign and we are 6 days
after surgery so that could be an infection.
When I was a student and I tried to answer questions
like this, I kind of start to feel my head start to spin
because it's a lot of information but
tell yourself just pause, take a breath.
If you feel like I'm overwhelmed, I can't keep all this information separate,
then just go back in the question when I show you the NCLEX format.
You see how you can easily go back in the question and
just follow client 1 all the way through to this point,
and then client 2 all the way through
to this point, client 3 and client 4.
That will help reorient yourself and help kind
of calm your nerves and diminish that confusion.
So, this was our format. Now, we're going to show you what this is
going to look like when you put everything side by side by side.
So, look at client 1.
You know my philosophy.
You can either go directly down on client 1 which
I would recommend then down 2, then 3, then 4.
Look at each piece of information. Is it normal or abnormal?
Heart rate for an adult of 107? That's fast.
Blood pressure of 82/40? That's low. So we have a heart
rate over 100, heart rate below 100. Respirations are fast.
Temperature, fairly normal. A little on the low side. Pulse ox is 94%.
That is right on the bottom of normal. So, they feel weird, they're dizzy.
They have a bruise on their abdomen. Their heart
rate is fast. Their blood pressure is low.
Their respiratory rate is fast. Their
temperature is not really that alarming.
Their pulse ox is still normal but
not fantastic for somebody that age.
This is how you keep walking through and take the other
information that you've read and piece it altogether.
Now client 2. Remember, was this an old person?
Was this a young person? Who was this person?
Well, they have a heart rate of 110 a minute. Is that normal?
Well, this is for an elderly client. Right?
but we've got a heart rate of 110, it's a little high.
Blood pressure is a little low, but not as low as 1.
Right? The blood pressure is not as low as 1.
Respirations are 20 a minute which is not as fast as 1. And temperature is
a little elevated, maybe considered a fever because it's higher than 98.6.
And their pulse ox is normal. So you're starting to keep comparison because
remember all of the game is is who of these 4 people is the most unstable.
Now, client 3. Okay, that's a little kiddo. So heart rate of 160.
We're not as concerned if that had been one of the adult clients.
Blood pressure 88/63. Remember to review your pediatric vital signs.
Respiratory rate 58. Okay, that's pretty fast. Isn't it?
But make sure you know your normals for
the pediatric children's vital signs.
Temp 37.9. Now, that's a little warm, but we know that
that kid felt warm to us. And their pulse ox is 98%.
So, not having any respiratory issues, but
he's definitely breathing pretty fast.
Client 4, heart rate 97 a minute. Uhhmm,
still normal but it's kind of high.
Blood pressure 148/92. That's high. Respiration of 22.
Uhhmm, kind of on the upper end.
I'm not super concerned about it, but it
is up more than I'd be comfortable with.
And 38 Celsius for a temperature or 104, just a little bit high.
But pulse ox is looking pretty solid.
So based on what I know, you just start to be formulating some opinions of
what you think and then do the work of comparing each of these clients.
Now, let's show you what it
looks like on the screen.
We wanted to break that all down for you so when you see this I don't want you
to get overwhelmed, there's no reason to be overwhelmed by these questions.
Take your time, be strategic, work through them left
to right, first to end, and you're going to do fine.
Look on the left side, information about the clients.
You'll see that you have the 3 tabs there.
You'll be able to go back and forth through those tabs as many
times as you want, but I always recommend go through them
thoroughly to make sure you see each
piece of information about them.
You see at the top, it reminds us that the
client presented to the ER on a Tuesday?
We know on the right hand side,
we have 4 clients. Right?
This is where we're going to do the work of the question and
figure out who is the highest priority of these patients?
Good news, we're not having to put them in order for 2nd, 3rd, or 4th
who should be seen, just identifying who is the highest priority.
Now, you see on tab 2 we've got the nurses
notes and you've already seen these.
Those says as things progressed from initially was 8 am to 8:30, now we've
moved on to 10 am in the morning and here's how things have changed.
That's why this is called a trend question. You're seeing a
trend of vital signs and symptoms over a period of time.
Right side? Still stays the same; client 1, 2, 3 and 4.
3rd tab, let's take a look at it. Vital signs.
Now, you and I have already walked through all these, right, in detail but now I want
to be sure that you're crystal clear on what is going to look like on the NCLEX exam.
Now, our job is to compare each one of these clients,
see who is more unstable than the others. Right?
So, I always recommend doing this one at a time. So, client 1. I'm just going to start
with 1 because that's what he was randomly assigned and let's take a look at it.
Now I know that this gentleman had a motor vehicle accident yesterday.
I know that any time you have a trauma, you're at risk for bleeding.
Now, I'm going to say "Is there any signs in what
I've seen in these trends that he is bleeding?"
Well, he did have that weird bruising and
that's a sign of abdominal hemorrhage.
He feels weak, he feels dizzy, his blood pressure is low,
his heart rate is high. Those are signs of hypovolemia.
If he is bleeding into his abdomen,
he will be experiencing hypovolemia.
A blood pressure that low for a grown adult is really a sign that
catches my attention. So for now, this dude is pretty serious.
I'm worried about him bleeding into his abdomen and when the blood is in the
abdomen instead of in the intravascular vessels, we're going to have trouble.
Could leave him to shock. So for right now,
I'm going to watch this guy super closely.
But let's compare him to number 2. I do worry about
elderly patients when they become dehydrated.
I know that they're going to be confused and so these
things are lining up. But how do I know they're dehydrated?
Well, besides throwing up multiple times like 4 times
before they came in, 2 since they've been here,
I know that their heart rate is really
high and their blood pressure is low.
See, our first guy we think he might have
those signs because he's hemorrhaging.
We think client number 2 is having these signs of low volume because
they've thrown up so much and they've lost so much fluid through vomiting.
But if I had to pick between 1 and 2, alright
I'm going to leave them both in because I know
this can happen too so I'm going
to leave them both in for now.
If I'm looking at 3 and I saw the trend,
yeah, I really think this kid is teething.
And that's what the rush is and that is not going to trump our
trauma victim in client 1 or dehydrated elderly person in 2.
So number 3, I'm going to be
able to just cross you off.
Now, when I'm taking a test like this, I use the
write on wipe off board and I write 1, 2, 3, 4.
I wrote key notes about the patients and then I'll cross
through them as I eliminate them as long as I say why.
I'm eliminating client number 3 because they're just irritable,
little cranky likely from cutting teeth because that's normal.
All their other vital signs are normal, you know they're a little warm.
So client 3 is not more unstable than client 1 or 2.
Client 4, I really feel sorry for them because they're having this
severe pain, they had surgery 6 days ago, they do have a fever.
I'm always worried after surgery that someone could develop an
infection and they sure looks like what client number 4 is doing.
Fever, severe pain, and now they got the purulent drainage
from the site. That's very probable infection for them.
However, they are still more
stable than client 1 and client 2.
So I'm going to eliminate client number 4, I think that
they are sign of infection, they will get treatment,
we'll take care of them, but they're not
the most unstable client at this point.
So, we're left choosing between
client number 1 and client number 2.
Now, I think client number 2 is dehydrated and that's why their
vital signs are low and we need to replace those fluids.
But client number 1 is clearly the
most unstable when I compare the two.
Client number 1 is showing us multiple signs
that he is hemorrhaging inside his abdomen.
This could be a patient who is much more unstable and likely to
arrest or code or at the very least go into hypovolemic shock.
So number 1 is our most unstable client.
Now, they just happen to be number 1.
They won't do that or you on any of the other NCLEX test,
but on this one it happened to be client number 1.
Go back and look at your charting just a little bit more if you're
uncertain in any way and say "I know it's number 1", list all the reasons.
Bruising, bleeding, hemorrhaging, vital signs are
abnormal, blood pressure is low, heart rate is high.
He says he feels really dizzy and...there you go. I'm confident that
number 1 is the one, check the box, and submit your answer. And that's it.
You worked all the way
through a trend question.
Remember, as long as you are systematic,
methodical, read all of the nurses notes,
get those straight in your mind before you start eliminating
patients, you're going to do just fine on these questions.
So good luck and join us for more practice
questions in our NCLEX review course.