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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The client dressing her affected side first is not a finding that the nurse should report to the interprofessional care team, as it indicates that the client is following the proper technique for dressing after a stroke. Dressing the affected side first helps the client maintain range of motion and prevent contractures of the affected limbs.
Choice B reason: The client bearing weight on their arms when using crutches is not a finding that the nurse should report to the interprofessional care team, as it is a normal and expected way of using crutches. Bearing weight on the arms helps the client balance and support their body weight while walking with crutches.
Choice C reason: The client coughing when swallowing her medications is a finding that the nurse should report to the interprofessional care team, as it indicates that the client may have dysphagia, or difficulty swallowing, which is a common complication of stroke. Dysphagia can increase the risk of aspiration, pneumonia, dehydration, and malnutrition. The nurse should assess the client's swallowing ability and refer them to a speech-language pathologist for further evaluation and intervention.
Choice D reason: The client's caregiver filling a pill organizer weekly is not a finding that the nurse should report to the interprofessional care team, as it is a positive and helpful way of managing the client's medications. Filling a pill organizer weekly can help the client and the caregiver remember the medication names, doses, and schedules, and prevent medication errors or omissions.
Correct Answer is B
Explanation
Choice A reason: Creating diversionary activities for children is not the priority action for the nurse to take. This is a supportive intervention that can help the children cope with the stress and trauma of the disaster, but it should be done after the nurse has ensured the safety and well-being of the clients.
Choice B reason: Addressing the physical needs of clients is the priority action for the nurse to take. This is based on the principle of Maslow's hierarchy of needs, which states that the nurse should prioritize the most basic and essential needs of the clients, such as food, water, shelter, clothing, and medical care. The nurse should assess the clients for any injuries, illnesses, or chronic conditions, and provide appropriate interventions or referrals.
Choice C reason: Helping clients gather needed supplies is not the priority action for the nurse to take. This is a helpful intervention that can assist the clients to obtain the resources and materials they need to survive and recover from the disaster, but it should be done after the nurse has addressed the physical needs of the clients.
Choice D reason: Exploring feelings the clients are experiencing is not the priority action for the nurse to take. This is a therapeutic intervention that can facilitate the emotional and psychological healing of the clients, but it should be done after the nurse has addressed the physical needs of the clients. The nurse should also respect the clients' readiness and willingness to share their feelings, and avoid forcing or rushing the process.
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