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: Reporting the incident to local authorities is an important action, but it is not the first priority. The nurse should first assess the child's physical condition and provide any necessary care.
Choice B reason: Checking the child for injuries is the first action the nurse should take, as the child may have sustained physical harm from the abuse. The nurse should document any findings and report them to the appropriate authorities.
Choice C reason: Referring the parent to a social service agency is a helpful action, but it is not the first priority. The nurse should first ensure the child's safety and well-being.
Choice D reason: Enrolling the parent in anger management classes is a potential intervention, but it is not the first priority. The nurse should first address the immediate needs of the child and the family.
Correct Answer is D
Explanation
Choice A reason: A consultant is someone who provides expert advice or guidance on a specific topic or problem. A nurse case manager may act as a consultant when collaborating with other health care professionals or community agencies, but not when arranging for the delivery of medical equipment to the client's home.
Choice B reason: A systems allocator is someone who distributes or allocates resources or services within a system or organization. A nurse case manager may act as a systems allocator when managing the cost and quality of care for a client, but not when arranging for the delivery of medical equipment to the client's home.
Choice C reason: An advocate is someone who supports or defends the rights or interests of another person or group. A nurse case manager may act as an advocate when promoting the client's autonomy, dignity, and well-being, but not when arranging for the delivery of medical equipment to the client's home.
Choice D reason: A coordinator is someone who organizes or facilitates the activities or interactions of different people or groups. A nurse case manager acts as a coordinator when arranging for the delivery of medical equipment to the client's home, as this involves coordinating with the client, the provider, the supplier, and the insurance company.
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