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The nurse is assisting in the care of clients during a mass casualty event.

Exhibits

For each client, click to specify if the client should be assigned a red, yellow, or black tag. A tag color may be assigned to more than one client.

A.

Client 4

B.

Client 2

C.

Client 1

D.

Client 3

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"}}

Rationale

  • Client 1: Red tag. This client has a significant loss of blood and a low heart rate, indicating they are in critical condition and need immediate intervention to survive.
  • Client 2: Yellow tag. This client has second-degree burns and is in pain, but their condition is stable and not immediately life-threatening.
  • Client 3: Black tag. This client is unresponsive with multiple severe burn injuries and Cheyne-Stokes respirations, indicating a very poor prognosis and unlikely survival.
  • Client 4: Red tag. This client is experiencing severe chest pain and shortness of breath, which could indicate a life-threatening condition such as a heart attack and requires immediate attention.


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Related Questions

Correct Answer is B

Explanation

A. Seclusion is a highly restrictive intervention and is not the first action for managing agitation in dementia clients.
B. Engaging the client in a repetitive activity as a distraction is the least restrictive intervention and can help calm the client by redirecting their attention. Non-pharmacological and less restrictive approaches are preferred as initial responses to manage agitation in dementia clients.
C. Administering PRN haloperidol IM is a pharmacological intervention and should be reserved for situations where less restrictive measures have failed.
D. Applying wrist restraints is a restrictive intervention that can increase agitation and is not appropriate as a first-line approach.

Correct Answer is D

Explanation

A. Asking each nurse for information about the problem is essential, but it should occur after addressing the immediate need for privacy.
B. Listening to the concerns of each staff nurse is important, but doing so in a private area ensures confidentiality and reduces further escalation.
C. Discussing ways to resolve the conflict is necessary, but first creating a safe and private environment is vital for open communication.
D. Moving the staff nurses to a private area is the first step to ensure they can discuss their conflict without external pressures or interruptions, which facilitates a more constructive dialogue.

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