A nurse in the emergency department is performing triage for a group of clients who were in a train crash. Which of the following clients should the nurse tag as emergent?

A client who has an open fracture of the femur

A client who has periorbital ecchymosis

A client who has a deep partial thickness burn on the lower extremities

A client who has an asymmetrical thorax

Answer and Explanation

The Correct Answer is D

Rationale for A: An open fracture of the femur is serious and requires prompt treatment, but it does not typically indicate an immediate life threat compared to other conditions.

Rationale for B: Periorbital ecchymosis can indicate facial trauma, but it is not necessarily life-threatening and would not be prioritized as emergent.

Rationale for C: A deep partial thickness burn on the lower extremities is significant and requires treatment, but unless the burn covers a large area or is complicated by other factors, it is not the most critical issue compared to respiratory or cardiovascular threats.

Rationale for D: An asymmetrical thorax may suggest a possible pneumothorax or other significant respiratory issue, which could lead to respiratory distress or failure. This client should be tagged as emergent due to the potential for rapid deterioration.

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Correct Answer is C

Explanation

A. While religious beliefs may influence a client's decision, they are not the deciding factor. Clients have the right to refuse treatment regardless of the reason, as long as they are competent and informed.

B. The partner’s role as the durable power of attorney for health care is only relevant if the client is unable to make decisions due to incompetence or incapacitation. If the client is competent, their decision takes precedence over the wishes of their partner or any legal proxy.

C. Ensuring the client understands the risks of refusing the procedure is the deciding factor. A competent client has the right to refuse any medical treatment, including surgery, after being informed of the potential consequences. The nurse and provider must ensure the client’s decision is informed and voluntary.

D. The facility ethics committee may provide guidance in complex cases, but they do not override a competent client’s autonomy. The client’s informed decision is the ultimate determinant in whether the surgery is performed.

A. "I will ask your mother's primary care provider to speak with you." B. "You will have to speak directly to your mother about her treatment." C. "What would you like to know about your mother's treatment?" D. "I cannot provide this information to you without your mother's consent."

Correct Answer is D

Explanation

A. Referring the adult child to the primary care provider might not immediately address the information needed.
B. Directing the adult child to speak solely with the mother might not be the most helpful approach to gather necessary information.
C. Inviting the adult child to specify what information they seek is not correct as they would have to get this information from their mother or their mother wil have to consent.
D. It is the role of the nurse to inform the child that they cannot disclose that information since patient confidentiality is a priority.

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A nurse in the emergency department is performing triage for a group of clients who were in a train crash. Which of the following clients should the nurse tag as emergent?

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Naxlex Comprehensive Predictor Exams

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