A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
A client who has a small circular partial-thickness burn of the left calf.
A client who has severe respiratory stridor and a deviated trachea.
A client who has a splinted open fracture of the left medial malleolus.
A client who has a massive head injury and is experiencing seizures.
The Correct Answer is B
Choice A reason: A Client Who Has a Small Circular Partial-Thickness Burn of the Left Calf
A small circular partial-thickness burn of the left calf is considered a minor injury in the context of a mass casualty event. This type of injury does not pose an immediate threat to life and can be managed after more critical cases are addressed. In mass casualty triage, patients with minor injuries are often categorized as “green” or “minimal” and are treated last.
Choice B reason: A Client Who Has Severe Respiratory Stridor and a Deviated Trachea
A client with severe respiratory stridor and a deviated trachea should be assessed first. These symptoms indicate a potential airway obstruction, which is a life-threatening condition requiring immediate intervention. In mass casualty triage, patients with compromised airways are given the highest priority and are categorized as “red” or “immediate” because their condition is critical and requires urgent medical attention.
Choice C reason: A Client Who Has a Splinted Open Fracture of the Left Medial Malleolus
A splinted open fracture of the left medial malleolus is a serious injury but not immediately life-threatening if properly splinted. This client would be categorized as “yellow” or “delayed” in mass casualty triage, meaning they require medical attention but can wait until more critical patients are stabilized.
Choice D reason: A Client Who Has a Massive Head Injury and Is Experiencing Seizures
A client with a massive head injury and experiencing seizures is in a critical condition. However, in the context of mass casualty triage, the immediate priority is to secure the airway, breathing, and circulation. While this client is in dire need of medical attention, the presence of severe respiratory stridor and a deviated trachea in another client takes precedence due to the immediate threat to life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Administer the Medications 5 Minutes Apart
Administering the medications 5 minutes apart is crucial when using multiple eye drops. This practice ensures that each medication has enough time to be absorbed without being washed out by the subsequent drop. This is particularly important for medications like timolol and pilocarpine, which are used to manage intraocular pressure in glaucoma.
Choice B reason: Hold Pressure on the Conjunctival Sac for 2 Minutes Following Application of Drops
Holding pressure on the conjunctival sac (punctal occlusion) for 2 minutes after applying eye drops can help reduce systemic absorption and increase the local effect of the medication. However, this instruction is not as critical as the timing between administering different eye drops.
Choice C reason: It Is Not Necessary to Remove Contact Lenses Before Administering Medications
This statement is incorrect. Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. The lenses can be reinserted after a sufficient amount of time has passed, usually around 15 minutes.
Choice D reason: Administer the Medications by Touching the Tip of the Dropper to the Sclera of the Eye
This statement is incorrect. The tip of the dropper should never touch the eye or any other surface to avoid contamination. The correct method is to hold the dropper above the eye and squeeze out the prescribed number of drops into the conjunctival sac.
Correct Answer is D
Explanation
Choice A reason: Low-Grade Fever
Low-grade fever is a common early symptom of rheumatoid arthritis (RA). It is often associated with the body’s inflammatory response to the autoimmune activity occurring in the joints. While it can persist throughout the disease, it is not considered a late manifestation.
Choice B reason: Weight Loss
Weight loss can occur in RA due to chronic inflammation and its effects on metabolism and appetite. However, it is more commonly seen in the early to middle stages of the disease rather than as a late manifestation. Persistent inflammation can lead to muscle wasting and weight loss, but these are not specific to the advanced stages of RA.
Choice C reason: Anorexia
Anorexia, or loss of appetite, is another symptom that can be present in RA. It is often related to the chronic inflammation and pain associated with the disease, which can reduce a person’s desire to eat. Like weight loss, anorexia can occur at various stages of RA and is not specifically a late manifestation.
Choice D reason: Knuckle Deformity
Knuckle deformity is a late manifestation of rheumatoid arthritis. As RA progresses, the chronic inflammation can lead to joint damage and deformities, particularly in the hands and fingers. This includes changes such as ulnar deviation, swan neck deformities, and boutonnière deformities. These deformities result from the destruction of joint tissues and the formation of scar tissue, which can significantly impair hand function.
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