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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "A cesarean birth is the only way to prevent transmission." Cesarean delivery is considered if active lesions or prodromal symptoms are present at the time of labor. However, it is not automatically required for all clients with a history of herpes.
B. "If you notice genital tingling be sure to notify your provider." Genital tingling or burning can be a prodromal sign of an impending herpes outbreak. Early reporting allows for appropriate evaluation and potential antiviral treatment to reduce the risk of transmission to the newborn.
C. "Hydrotherapy during labor can help reduce transmission." Hydrotherapy has no effect on herpes virus transmission and is not used for this purpose. Preventing neonatal herpes depends on careful monitoring and antiviral management.
D. "The provider will perform weekly visual inspections for lesions." Routine weekly inspections are not standard unless symptoms suggest an outbreak. Clients are generally monitored and evaluated for lesions closer to labor or if symptoms arise.

A. Provide frequent stimulation for the newborn. B. Encourage frequent eye contact with the newborn during feedings. C. Decrease the lighting levels in the nursery. D. Wrap the newborn loosely in a blanket

Correct Answer is C

Explanation

A. Provide frequent stimulation for the newborn. Excessive stimulation can worsen symptoms in newborns with neonatal abstinence syndrome (NAS), including irritability, tremors, and difficulty sleeping. These infants need a calm, low-stimulation environment to reduce neurologic stress.
B. Encourage frequent eye contact with the newborn during feedings. While bonding is important, prolonged or forced eye contact can overstimulate a newborn with NAS. These infants often have difficulty regulating sensory input and may become more irritable with excessive interaction.
C. Decrease the lighting levels in the nursery. A dim, quiet environment helps soothe infants experiencing NAS. Reducing lighting can minimize sensory overload, promote rest, and support neurologic regulation during withdrawal.
D. Wrap the newborn loosely in a blanket. Loose wrapping does not provide the security and containment that helps calm an overstimulated infant. Instead, swaddling the newborn snugly can reduce tremors, promote sleep, and offer comfort during withdrawal symptoms.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a history of genital herpes and is at 32 weeks of gestation. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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