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. Diphenhydramine. Urticaria (hives) is a common allergic reaction often caused by medications like antibiotics. Diphenhydramine, an antihistamine, is used to treat allergic reactions by blocking histamine receptors, reducing itching, swelling, and rash.
B. Hydralazine. This is an antihypertensive medication used to treat high blood pressure, not allergic reactions. It has no effect on histamine or allergic symptoms.
C. Naloxone. Naloxone is an opioid antagonist used to reverse opioid overdose. It does not treat allergic reactions like urticaria unless the cause is opioid-induced (which is not indicated here).
D. Protamine. Protamine is used to reverse the effects of heparin. It has no role in treating allergic reactions to antibiotics.
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"C"}
Explanation
The client presents with symptoms suggestive of severe preeclampsia, including headache, nausea, right upper quadrant pain, facial and dependent edema, rapid weight gain, and 3+ deep tendon reflexes (hyperreflexia). Hyperreflexia is a sign of central nervous system irritability, which can precede seizures (eclampsia) and increase the risk for placental abruption—a premature separation of the placenta from the uterine wall. This is a medical emergency that can result in fetal and maternal complications.
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