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: People who have substance use disorders are not the fastest growing segment of the homeless population, although they are a significant and vulnerable group. Substance use disorders may contribute to or result from homelessness, but they are not the primary cause of the increase in homelessness.
Choice B reason: Families who have children are the fastest growing segment of the homeless population, according to the U.S. Department of Housing and Urban Development (HUD). The number of homeless families with children increased by 9% from 2019 to 2020, and they accounted for 34% of the total homeless population in 2020. The main causes of family homelessness are lack of affordable housing, poverty, unemployment, domestic violence, and health problems.
Choice C reason: Adolescent runaways are not the fastest growing segment of the homeless population, although they are a high-risk and underserved group. Adolescent runaways may face challenges such as abuse, exploitation, mental health issues, and lack of education and employment opportunities. However, the number of homeless youth is difficult to estimate due to their hidden and transient nature.
Choice D reason: Men who are unemployed are not the fastest growing segment of the homeless population, although they are a large and diverse group. Men who are unemployed may face barriers such as low wages, lack of skills, discrimination, and health problems. However, the number of homeless men has decreased by 5% from 2019 to 2020, and they accounted for 60% of the total homeless population in 2020.
Correct Answer is B
Explanation
Choice A reason: This comment does not indicate rationalization, but rather a recognition of the consequences of obesity. The client may be expressing a need for help or motivation to change their lifestyle.
Choice B reason: This comment indicates rationalization, which is a defense mechanism that involves making excuses or justifying one's behavior or situation. The client may be avoiding personal responsibility or denying the possibility of change by blaming their obesity on their genes.
Choice C reason: This comment does not indicate rationalization, but rather a challenge or barrier that the client faces in achieving their health goals. The client may be acknowledging their weakness or seeking support to overcome their temptation.
Choice D reason: This comment does not indicate rationalization, but rather a projection or displacement of the client's negative feelings onto others. The client may be feeling insecure or rejected because of their obesity, and assuming that others share the same opinion.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today