An emergency department nurse triages a group of clients who were injured in a school bus crash. Which of the following clients should the nurse have the provider evaluate first?
A client who has a forehead wound that is bleeding copiously
A client who has a compound fracture of the femur and is crying in pain
A client who was unconscious at the scene and now reports diplopia and nausea
A client who has several missing teeth and a swollen, ecchymotic upper lip
The Correct Answer is C
A. A client who has a forehead wound that is bleeding copiously. Although bleeding may appear dramatic, most scalp wounds bleed heavily and can be controlled with pressure. This is not immediately life-threatening if the client is stable.
B. A client who has a compound fracture of the femur and is crying in pain. This is a serious injury with risk for blood loss and infection, but the client is alert and stable enough to express pain, suggesting less immediate neurologic risk than other clients.
C. A client who was unconscious at the scene and now reports diplopia and nausea. This client likely has a head injury with signs of increased intracranial pressure or concussion (diplopia = double vision, nausea, and prior loss of consciousness). These are neurological red flags and require immediate evaluation to prevent deterioration.
D. A client who has several missing teeth and a swollen, ecchymotic upper lip. While painful and concerning, oral trauma without airway compromise is less urgent than potential brain injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Shows perfectionism. Clients with obsessive-compulsive personality disorder (OCPD) are characterized by perfectionism, a preoccupation with orderliness, control, and rules, and a need for mental and interpersonal control, often at the expense of flexibility and efficiency.
B. Takes advantage of others. This behavior is more typical of antisocial personality disorder, not OCPD. Clients with OCPD tend to be highly conscientious, not manipulative or exploitative.
C. Irritability. While clients with OCPD may become frustrated or anxious if things are not done their way, chronic irritability is not a hallmark feature of the disorder.
D. Impulsivity. Impulsivity is more commonly associated with borderline or antisocial personality disorders. In contrast, clients with OCPD are typically rigid, cautious, and rule-bound.
Correct Answer is D
Explanation
A. Offer the client saltine crackers between meals. Saltine crackers are dry and salty, which can worsen symptoms of xerostomia (dry mouth) by further irritating and drying the oral mucosa. Moist, soft foods are more appropriate.
B. Suggest rinsing his mouth with an alcohol-based mouth wash. Alcohol-based mouthwashes should be avoided in clients with dry mouth as they can exacerbate oral dryness and irritation. Alcohol-free rinses are recommended instead.
C. Instruct the client on the use of esophageal speech. Esophageal speech is used in clients who have had laryngectomies, not those experiencing xerostomia. This intervention is unrelated to the client's current condition.
D. Provide humidification of the room air. Using a humidifier adds moisture to the environment, which helps relieve oral dryness and makes the client more comfortable, especially during sleep or in dry indoor climates.
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