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A community health nurse is triaging clients following a worksite explosion.

Exhibits
Select the 2 clients that the nurse should identify as requiring immediate care.

A.

Client 1

B.

Client 2

C.

Client 3

D.

Client 4

E.

Client 5

F.

Client 6

Answer and Explanation

Correct Answer : D,F

  • Client 1: This client has a minor laceration with minimal drainage and stable vital signs. No signs of shock or infection are present. This injury is not life-threatening and can wait, making this client a low-priority (green-tag) case.
  • Client 2: Although this client is experiencing worsening pain and signs of mild hypovolemia, they are alert and have stable vital signs. This client needs prompt care, but not immediate life-saving interventions, making them a delayed (yellow-tag) priority.
  • Client 3: The client has a mild head injury with stable neurological signs and no evidence of increased intracranial pressure or altered consciousness. This presentation does not require immediate intervention and would also be triaged as delayed.
  • Client 4: This client presents with signs of severe traumatic brain injury—fixed pupils, decorticate posturing, and irregular respirations—which indicate brainstem dysfunction. Although the prognosis is poor, the condition is immediately life-threatening and requires urgent airway and neurological support, making this client a top priority (red-tag).
  • Client 5: This client has an open fracture and reports significant pain but has stable vital signs and adequate circulation. The injury requires treatment but is not immediately life-threatening, so they can be managed later (yellow-tag).
  • Client 6: The client shows signs of progressing respiratory distress—tripod positioning, retractions, anxiety, and diminished breath sounds—indicating possible airway compromise from inhalation injury. This is an urgent, potentially fatal condition requiring immediate airway management (red-tag).


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Related Questions

Correct Answer is B

Explanation

A. Disregard differences in the nurse's and clients' beliefs: Ignoring differences in beliefs can create barriers to effective spiritual care and decrease client engagement. Understanding and respecting clients' beliefs is essential for meaningful outcomes.

B. Reassess the social demographics of the faith community: If outcomes are not met, it’s important to review characteristics like age, culture, language, and spiritual needs of the community. This helps tailor the program to better fit the population and increase its relevance and effectiveness.

C. Apply objective measurements for the outcomes: While measuring outcomes is important, if initial goals were not achieved, reassessment of the community context is necessary before changing measurement methods.

D. Provide programs without an emphasis on spiritual care: Removing spiritual care defeats the purpose of the program and may decrease client satisfaction and holistic support. Instead, adaptations should enhance relevance, not eliminate focus.

Correct Answer is ["A","B","C","E"]

Explanation

A. Limit screen use to 2 hr per day: Limiting screen time to no more than 2 hours daily aligns with pediatric guidelines and supports healthy brain development, social interaction, and physical activity in toddlers.

B. Encourage supervised outdoor exploration: Supervised outdoor play promotes physical development, gross motor skills, and sensory experiences while ensuring safety. It supports curiosity and learning in toddlers.

C. Participate in loosely structured play settings: Loosely structured play allows toddlers to explore creatively and develop social skills without rigid rules, fostering cognitive and emotional growth appropriate for their developmental stage.

D. Sign up for organized sports: Organized sports are generally not recommended for toddlers due to their limited attention span, motor skills, and the structured nature of sports. This is more appropriate for older children.

E. Introduce items of various textures for tactile play: Tactile play with varied textures enhances sensory processing, fine motor skills, and cognitive development, which are crucial during the toddler years.

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