Nokea
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. A client who has superficial partial-thickness burn injuries over 5% of his body
- B. A client who has a femur fracture with a 2+ pedal pulse
- C. A client who is ambulatory and exhibits manic behavior
- D. A client who has a rigid abdomen with manifestations of shock
Correct Answer: D
Rationale: The correct answer is D: A client who has a rigid abdomen with manifestations of shock. This client should receive treatment priority because a rigid abdomen can indicate internal bleeding or organ damage, which are life-threatening conditions requiring immediate medical attention to prevent further complications. Manifestations of shock, such as hypotension and tachycardia, also indicate a critical condition that needs urgent intervention to stabilize the client's condition and prevent deterioration.
Choice A is incorrect because superficial partial-thickness burn injuries, although painful and requiring treatment, are not immediately life-threatening compared to internal injuries like in choice D. Choice B is incorrect as a femur fracture with a palpable pedal pulse indicates distal circulation is intact, making it a lower priority compared to the critical condition in choice D. Choice C is incorrect as manic behavior, while concerning, does not pose an immediate threat to the client's life compared to the potentially life-threatening conditions in choice D.
You may also like to solve these questions
A nurse is counseling a client who has a new diagnosis of chlamydia. Which of the following information should the nurse include in the teaching? (Select all that apply)
- A. You should avoid sexual contact until therapy is complete
- B. Notify anyone with whom you have had sexual contact over the past 2 months
- C. You will need to take an antiviral medication for 30 days
- D. Once you complete treatment, you will have an acquired immunity against chlamydia
- E. You might experience painful urination until the infection has resolved
Correct Answer: A, B, E
Rationale: The correct answers are A, B, and E. A is correct because avoiding sexual contact until therapy is complete helps prevent spreading chlamydia to others. B is correct as notifying sexual contacts allows for their treatment to prevent reinfection. E is correct because painful urination is a common symptom of chlamydia and should be expected until treatment resolves the infection. Choice C is incorrect because chlamydia is a bacterial infection, not a viral one, so antibiotics are used, not antivirals. Choice D is incorrect because completing treatment does not confer immunity against chlamydia; reinfection is possible.
A nurse is working to reduce individual and family violence in the local community. Which of the following actions by the nurse demonstrates a primary prevention strategy to achieve this goal?
- A. Conducting counseling for at-risk parents
- B. Assessing a family for marital discord
- C. Teaching parenting techniques to new parents
- D. Providing treatment for a young adult who has a substance use disorder
Correct Answer: C
Rationale: The correct answer is C: Teaching parenting techniques to new parents. This is a primary prevention strategy because it focuses on educating parents before any violence occurs. By providing new parents with effective parenting techniques, the nurse is helping to prevent the occurrence of violence in the first place. This intervention addresses the root cause and promotes a positive family environment.
Choices A, B, and D are not primary prevention strategies. Conducting counseling for at-risk parents (A) is a secondary prevention strategy as it aims to intervene with individuals already at risk. Assessing a family for marital discord (B) is also a secondary prevention strategy as it involves identifying existing issues. Providing treatment for a young adult with a substance use disorder (D) is a tertiary prevention strategy, focusing on treating the individual after the issue has already developed.
A newly hired occupational health nurse is assessing hazards in the work environment. Which of the following actions will help the nurse detect potential physical hazards?
- A. Track rates of illness caused by infection among employees
- B. Survey workers about job-related emotional stress
- C. Identify industrial toxins that are present in the environment
- D. Measure noise levels at various locations in the facility
Correct Answer: D
Rationale: The correct answer is D: Measure noise levels at various locations in the facility. This action will help the nurse detect potential physical hazards because excessive noise can lead to hearing loss and other health issues. By measuring noise levels, the nurse can identify areas where noise levels exceed safe limits and implement control measures.
Choice A is incorrect as it focuses on illness caused by infections, not physical hazards. Choice B is incorrect as it pertains to emotional stress, not physical hazards. Choice C is incorrect as it focuses on industrial toxins, which are chemical hazards, not physical hazards.
A faith-based organization asks a community health nurse to develop a mobile meal program for older adults. Which of the following actions should the nurse plan to take first?
- A. Determine potential funding sources for the program
- B. Inquire about the availability of volunteers
- C. Identify alternative solutions to address concerns
- D. Perform a needs assessment
Correct Answer: D
Rationale: The correct answer is D: Perform a needs assessment. This is because conducting a needs assessment is the first crucial step in program planning. It helps the nurse to gather data on the specific needs and preferences of older adults in the community. This data will guide the nurse in developing a mobile meal program that is tailored to meet the actual needs of the target population.
Option A: Determining potential funding sources should come after identifying the specific needs of the population, as funding sources will be based on the program's requirements.
Option B: Inquiring about the availability of volunteers is important but should be considered after understanding the needs of the older adults.
Option C: Identifying alternative solutions is premature without first understanding the actual needs of the population through a needs assessment.
In summary, performing a needs assessment is the first step as it provides essential information to guide the development of an effective and targeted mobile meal program for older adults.
A home health nurse is assessing a client who has AIDS. Which of the following responses by the client indicates a risk for suicide?
- A. I'm afraid of experiencing pain near the end.
- B. I know that everything will be better soon.
- C. I am relying more and more on my partner for support.
- D. I don't want to lose control of my ability to make decisions.
Correct Answer: B
Rationale: The correct answer is B: "I know that everything will be better soon." This response indicates a risk for suicide as it reflects a sense of hopelessness or feeling that things will not improve. This mindset is often associated with suicidal ideation.
A: Fear of pain near the end is a common concern in terminal illnesses but does not directly indicate suicide risk.
C: Relying on a partner for support can be a coping mechanism and does not necessarily indicate suicide risk.
D: Desire to maintain decision-making control is a sign of autonomy and does not directly indicate suicide risk.
In summary, choice B is correct as it suggests a lack of hope for the future, while the other choices do not directly indicate a risk for suicide.