A first-response team is working at the location of a bombing incident. A nurse triaging a group of clients should give treatment priority to which of the following clients?
A client who has a rigid abdomen with manifestations of shock.
A client who has a femur fracture with a 2+ pedal pulse.
A client who is ambulatory and exhibits manic behavior.
A client who has superficial partial-thickness burn injuries over 5% of his body.
A client who has superficial partial-thickness burn injuries over 5% of his body.
The Correct Answer is A
The correct answer is Choice A because, a client who has a rigid abdomen with manifestations of shock. This client is showing signs of internal bleeding and hypovolemic shock, which is a medical emergency that requires immediate treatment to prevent further complications or death. Therefore, the priority should be given to this client.
Choice B is wrong because, a client who has a femur fracture with a 2+ pedal pulse, has a stable condition and can wait for treatment. Choice C is wrong because, a client who is ambulatory and exhibits manic behavior, is not a medical emergency and can wait for treatment. Choice D is wrong because, a client who has superficial partial-thickness burn injuries over 5% of his body, can wait for treatment as these injuries are not life-threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C because, "Refer clients to the appropriate community agency if signs of abuse are evident." This is the correct answer because it is an appropriate secondary prevention strategy related to violence and abuse. By referring clients to the appropriate community agency, the nurse is providing a proactive measure to prevent further harm and ensure that the client receives appropriate care.
Choice Ais wrong because, "Teach a parenting skills class at a child development center," is not the correct answer because it is a primary prevention strategy and not related to violence and abuse.
Choice Bis wrong because, "Assess clients for withdrawal and passivity during home health visits," is not the correct answer because it is a secondary prevention strategy related to depression, not violence and abuse.
Choice Dis wrong because, "Coordinate a personal defense program at a local agency," is not the correct answer because it is a tertiary prevention strategy and not related to violence and abuse.
Correct Answer is D
Explanation
The correct answer is Choice D because "Explore possible solutions with the partner." When a hospice nurse is concerned that the partner of a client is experiencing caregiver burden, the first step is to explore possible solutions with the partner. This involves assessing the partner's needs, concerns, and limitations, and working collaboratively to develop a plan of care that meets the needs of both the client and the partner. This may involve arranging for additional support, such as respite care or home health services, or modifying the care plan to make it more manageable for the partner.
Choice A is wrong because Suggesting assistive personnel visits daily to provide client care (Choice A is wrong because) may provide additional support, but it does not address the partner's caregiver burden.
Choice B is wrong because Teaching the partner about getting enough rest (Choice B is wrong because) may be helpful, but it does not address the underlying caregiver burden and may be perceived as dismissive of the partner's concerns.
Choice C is wrong because Encouraging the partner to invite family members to assist with client care (Choice C is wrong because) may provide additional support, but it assumes that the partner has family members who are available and willing to assist and does not address the underlying caregiver burden.
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