A client is brought to the Emergency Department as one of the first victims of a train accident. The client reports light-headedness, a weak pulse, and uncontrolled bleeding. Which priority tag should a triage nurse use to categorize this client?

Black tag

Red tag

Green tag

Yellow tag

Answer and Explanation

The Correct Answer is B

Choice A reason: A black tag is not the appropriate priority tag for this client, as it indicates that the client is dead or has injuries that are incompatible with life. A black tag is used for clients who have no signs of life, such as pulse, respiration, or pupillary response, or who have severe injuries that cannot be treated with the available resources, such as massive head trauma, decapitation, or incineration. A black tag means that no further care or intervention is provided to the client.

Choice B reason: A red tag is the appropriate priority tag for this client, as it indicates that the client has life-threatening injuries that require immediate attention and treatment. A red tag is used for clients who have compromised airway, breathing, or circulation, such as respiratory distress, shock, severe bleeding, chest pain, or head injury. A red tag means that the client is given the highest priority and is treated as soon as possible.

Choice C reason: A green tag is not the appropriate priority tag for this client, as it indicates that the client has minor injuries that do not require urgent care or intervention. A green tag is used for clients who have stable vital signs and can walk or move without assistance, such as abrasions, sprains, fractures, or minor burns. A green tag means that the client is given the lowest priority and is treated after all other clients.

Choice D reason: A yellow tag is not the appropriate priority tag for this client, as it indicates that the client has serious injuries that require observation and treatment within a short time frame. A yellow tag is used for clients who have potential complications or deterioration of their condition, such as abdominal pain, pelvic injury, open wounds, or spinal injury. A yellow tag means that the client is given the second highest priority and is treated within 30 to 60 minutes.

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Correct Answer is B

Explanation

Choice A: Limit fluid intake to prevent incontinence. This is incorrect because limiting fluid intake can lead to dehydration, urinary tract infections, and kidney stones. Fluid intake should be adequate to maintain hydration and flush out bacteria from the urinary tract.

Choice B: Provide regular perineal care to prevent skin breakdown. This is correct because reflex incontinence can cause urine leakage and skin irritation, which can increase the risk of infection and pressure ulcers. Regular perineal care can help keep the skin clean and dry, and prevent complications.

Choice C: Administer hypotonic IV fluids. This is incorrect because hypotonic IV fluids can cause fluid overload, hyponatremia, and cerebral edema. Hypotonic IV fluids are not indicated for clients with reflex incontinence.

Choice D: Teach Kegel exercises to strengthen the pelvic floor. This is incorrect because Kegel exercises are effective for clients with stress or urge incontinence, but not for clients with reflex incontinence. Reflex incontinence is caused by a loss of voluntary control over the bladder due to a spinal cord injury, and Kegel exercises cannot restore this function.

A. Gradual onset of several hours B. Maintains consciousness C. Sudden severe headache D. History of neurologic deficits lasting less than 1 hr.

Correct Answer is C

Explanation

Choice A reason: Gradual onset of several hours is not a manifestation of a hemorrhagic stroke. A hemorrhagic stroke occurs when a blood vessel in the brain bursts, causing bleeding into the surrounding tissue. This usually happens suddenly and without warning, and can cause rapid deterioration of the client's condition.

Choice B reason: Maintains consciousness is not a manifestation of a hemorrhagic stroke. A hemorrhagic stroke can cause increased intracranial pressure, which can compress the brain and impair its function. This can lead to loss of consciousness, coma, or death.

Choice C reason: Sudden severe headache is a manifestation of a hemorrhagic stroke. A hemorrhagic stroke can cause intense pain in the head, neck, or face, due to the pressure and irritation of the bleeding. The headache may be described as "the worst headache of my life" or "thunderclap headache".

Choice D reason: History of neurologic deficits lasting less than 1 hr. is not a manifestation of a hemorrhagic stroke. This is a characteristic of a transient ischemic attack (TIA), which is also known as a mini-stroke. A TIA occurs when a blood clot temporarily blocks an artery in the brain, causing temporary symptoms such as weakness, numbness, vision loss, or speech difficulty. A TIA does not cause permanent damage to the brain, but it is a warning sign of a possible future stroke.

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A client is brought to the Emergency Department as one of the first victims of a train accident. The client reports light-headedness, a weak pulse, and uncontrolled bleeding. Which priority tag should a triage nurse use to categorize this client?

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