A first response team is working at the location of a bombing incident. A nurse triaging a group of clients should give treatment priority to which of the following clients?
A client who has superficial partial-thickness burn injuries over 5% of his body.
A client who has a femur fracture with a 2+ pedal pulse.
A client who is ambulatory and exhibits manic behavior.
A client who has a rigid abdomen with manifestations of shock.
The Correct Answer is D
Choice A reason: A client who has superficial partial-thickness burn injuries over 5% of his body is not the highest priority for treatment. This type of burn injury affects only the epidermis and the upper layer of the dermis, and causes pain, redness, and blisters. The client may need fluid replacement, pain management, and wound care, but is not in immediate danger of life-threatening complications.
Choice B reason: A client who has a femur fracture with a 2+ pedal pulse is not the highest priority for treatment. This type of fracture involves the breakage of the thigh bone, which is the largest and strongest bone in the body. The client may experience severe pain, swelling, deformity, and bleeding. A 2+ pedal pulse indicates that the blood flow to the lower extremity is adequate, but not optimal. The client may need immobilization, traction, surgery, and infection prevention, but is not in immediate danger of life-threatening complications.
Choice C reason: A client who is ambulatory and exhibits manic behavior is not the highest priority for treatment. This type of behavior involves a state of elevated mood, energy, and activity, which may be caused by stress, trauma, or a mental disorder. The client may experience euphoria, irritability, impulsivity, and poor judgment. The client may need psychological support, medication, and safety measures, but is not in immediate danger of life-threatening complications.
Choice D reason: A client who has a rigid abdomen with manifestations of shock is the highest priority for treatment. This type of condition involves a severe injury to the abdominal organs, such as the liver, spleen, or intestines, which may cause internal bleeding, inflammation, and infection. The client may experience pain, tenderness, distension, and guarding of the abdomen, as well as signs of shock, such as hypotension, tachycardia, pallor, and confusion. The client may need fluid resuscitation, blood transfusion, surgery, and antibiotics, and is in immediate danger of life-threatening complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Alerting the family members of coworkers about possible exposure to anthrax is not an action that the nurse should take. Anthrax is not contagious, and it cannot be spread from person to person. The family members of coworkers are not at risk of infection, and alerting them may cause unnecessary panic and stigma.
Choice B reason: Placing the employee under quarantine for 14 days is not an action that the nurse should take. Anthrax is not contagious, and it cannot be spread from person to person. The employee does not need to be isolated from others, and quarantine may interfere with their access to medical care and social support.
Choice C reason: Referring coworkers who might have been exposed to a provider for prophylactic antibiotics is an action that the nurse should take. Anthrax is a serious bacterial infection that can be fatal if left untreated. The coworkers who might have been exposed to the same source of anthrax as the employee should receive prophylactic antibiotics as soon as possible to prevent the infection from developing.
Choice D reason: Instructing the employee to wear a mask at work is not an action that the nurse should take. Anthrax is not contagious, and it cannot be spread from person to person. The employee does not need to wear a mask at work, and doing so may cause unnecessary discomfort and discrimination.
Correct Answer is C
Explanation
Choice A reason: Helping the client apply for Medicare is not the best action by the nurse, as Medicare is a federal health insurance program for people who are 65 or older, disabled, or have end-stage renal disease. The client does not meet any of these criteria and may not be eligible for Medicare.
Choice B reason: Exploring options for alternative therapies is not the best action by the nurse, as alternative therapies may not be effective or safe for treating tuberculosis. Tuberculosis is a serious bacterial infection that requires specific antibiotics to cure. Alternative therapies may also interfere with the prescribed medication or cause adverse effects.
Choice C reason: Arranging for medication through local agencies is the best action by the nurse, as it ensures that the client receives the appropriate treatment for tuberculosis. Local agencies may have programs or resources that can help the client access free or low-cost medication. The nurse should also educate the client about the importance of adhering to the medication regimen and completing the course of treatment.
Choice D reason: Sending the client to the nearest facility for further evaluation is not the best action by the nurse, as it may delay the initiation of treatment and increase the risk of transmission of tuberculosis to others. The client already has a diagnosis of tuberculosis and needs to start the treatment as soon as possible. The nurse should also advise the client to wear a mask and avoid close contact with others until the infection is no longer contagious.
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