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: 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.
Correct Answer is D
Explanation
Choice A reason: Implementing a disaster triage plan with a local medical facility is not an action that the nurse is engaging in disaster preparedness efforts. This is an action that the nurse is engaging in disaster response efforts, which are the actions taken during or immediately after a disaster to save lives, minimize injuries, and protect property.
Choice B reason: Functioning as a manager at a temporary shelter is not an action that the nurse is engaging in disaster preparedness efforts. This is an action that the nurse is engaging in disaster recovery efforts, which are the actions taken after a disaster to restore the normal functioning of the community and the environment.
Choice C reason: Assisting with the identification of a biological agent is not an action that the nurse is engaging in disaster preparedness efforts. This is an action that the nurse is engaging in disaster mitigation efforts, which are the actions taken before, during, or after a disaster to reduce or eliminate its impact.
Choice D reason: Organizing a mass casualty drill for community members is an action that the nurse is engaging in disaster preparedness efforts. This is an action that the nurse is engaging in disaster prevention efforts, which are the actions taken before a disaster to prevent or minimize its occurrence or effects. A mass casualty drill is a simulation exercise that tests the readiness and capacity of the health care system and the community to respond to a large-scale emergency.
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