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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Handrails are present in the bathroom: Handrails in the bathroom are actually a safety feature, not a risk. They provide support and stability, helping to prevent falls, especially for individuals with decreased vision or mobility issues.
Choice B reason:
Electrical cords are placed along the walls: Electrical cords placed along the walls can pose a tripping hazard, particularly for someone with decreased vision. However, if they are secured properly and not in walkways, the risk can be minimized.
Choice C reason:
Uses a microwave for cooking: Using a microwave for cooking is generally safe and convenient for older adults, especially those with decreased vision. It reduces the risk of burns and fires compared to using a stove.
Choice D reason:
Scatter rugs are present in the kitchen: Scatter rugs are a significant safety risk for older adults, particularly those with decreased vision. They can easily cause tripping and falls, which can lead to serious injuries. It is recommended to remove scatter rugs or ensure they are non-slip and securely fastened.
Correct Answer is A
Explanation
Choice A reason:
A sudden decrease in abdominal pain can indicate that the appendix has perforated. When the appendix bursts, the pressure is relieved, leading to a temporary reduction in pain. However, this is quickly followed by severe pain and signs of peritonitis, such as a rigid abdomen and high fever.
Choice B reason:
The absence of Rovsing’s sign is not a specific indicator of a perforated appendix. Rovsing’s sign is a clinical test used to diagnose appendicitis, where pain is elicited in the right lower quadrant when the left lower quadrant is palpated. Its absence does not necessarily indicate perforation.
Choice C reason:
A low-grade fever is a common symptom of appendicitis but does not specifically indicate perforation. A perforated appendix typically leads to a high fever due to the spread of infection within the abdomen.
Choice D reason:
A rigid abdomen is a sign of peritonitis, which can occur after the appendix has perforated. While this is an important symptom, the sudden decrease in pain followed by severe symptoms is more indicative of perforation.
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