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 B
Explanation
Choice A reason: Arranging for Meals on Wheels assistance is not the priority action, as it does not address the underlying issue of the client's partner's refusal to help with feeding. Meals on Wheels may also not be suitable for the client's dietary needs and preferences.
Choice B reason: Determining the client's ability to self-feed is the priority action, as it will help the nurse assess the client's nutritional status and needs, as well as the level of support required from the partner or other caregivers. The nurse can also educate the partner on the importance of adequate nutrition and hydration for the client, and provide strategies to facilitate feeding.
Choice C reason: Directing the home health aide to assist with meals is not the priority action, as it may not be feasible or acceptable to the client or the partner. The home health aide may also not have the skills or training to assist with feeding a client with Alzheimer's disease.
Choice D reason: Referring the client's partner to an Alzheimer's support group is not the priority action, as it does not address the immediate problem of the client's lack of eating. However, it may be a helpful intervention in the long term, as it can provide the partner with emotional support, education, and resources to cope with the challenges of caring for a client with Alzheimer's disease.
Correct Answer is A
Explanation
Choice A reason: Collecting data to identify barriers to learning is the first action that the nurse should take. This is based on the principle of assessment, which states that the nurse should gather information about the needs, interests, and characteristics of the target population before planning any intervention. The nurse should assess the barriers that may prevent the adolescents from participating in or benefiting from the program, such as lack of knowledge, motivation, access, or support.
Choice B reason: Establishing methods to evaluate program outcomes is not the first action that the nurse should take. This is based on the principle of evaluation, which states that the nurse should measure the effectiveness and impact of the intervention after implementing it. The nurse should determine the criteria and indicators that will be used to evaluate the program outcomes, such as changes in knowledge, attitudes, behaviors, or health status.
Choice C reason: Obtaining visual aids that feature adolescents is not the first action that the nurse should take. This is based on the principle of implementation, which states that the nurse should deliver the intervention using appropriate strategies and resources. The nurse should obtain visual aids that are relevant, accurate, and appealing to the adolescents, and that can enhance the learning process and the message delivery.
Choice D reason: Providing computer-based education is not the first action that the nurse should take. This is based on the principle of implementation, which states that the nurse should deliver the intervention using appropriate strategies and resources. The nurse should provide computer-based education if it is feasible, accessible, and preferred by the adolescents, and if it can facilitate the learning objectives and outcomes.
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