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A community health nurse is triaging clients following a worksite explosion.

Exhibits
Select the 2 clients that the nurse should identify as requiring immediate care.

Client 1

Client 2

Client 3

Client 4

Client 5

Client 6

Answer and Explanation

Correct Answer : D,F

Client 1: This client has a minor laceration with minimal drainage and stable vital signs. No signs of shock or infection are present. This injury is not life-threatening and can wait, making this client a low-priority (green-tag) case.
Client 2: Although this client is experiencing worsening pain and signs of mild hypovolemia, they are alert and have stable vital signs. This client needs prompt care, but not immediate life-saving interventions, making them a delayed (yellow-tag) priority.
Client 3: The client has a mild head injury with stable neurological signs and no evidence of increased intracranial pressure or altered consciousness. This presentation does not require immediate intervention and would also be triaged as delayed.
Client 4: This client presents with signs of severe traumatic brain injury—fixed pupils, decorticate posturing, and irregular respirations—which indicate brainstem dysfunction. Although the prognosis is poor, the condition is immediately life-threatening and requires urgent airway and neurological support, making this client a top priority (red-tag).
Client 5: This client has an open fracture and reports significant pain but has stable vital signs and adequate circulation. The injury requires treatment but is not immediately life-threatening, so they can be managed later (yellow-tag).
Client 6: The client shows signs of progressing respiratory distress—tripod positioning, retractions, anxiety, and diminished breath sounds—indicating possible airway compromise from inhalation injury. This is an urgent, potentially fatal condition requiring immediate airway management (red-tag).

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Correct Answer is ["A","D","E"]

Explanation

A. Teaching a class about the risks of cigarette smoking: This is a primary prevention activity focused on educating children to prevent the initiation of smoking and related health problems before they occur.

B. Recommending a seating arrangement for a child in a body cast: This is a tertiary prevention activity that involves managing existing health conditions and preventing complications, not primary prevention.

C. Creating a plan of care for children who have a diagnosis of diabetes mellitus: This is tertiary prevention since it deals with managing an existing chronic illness to reduce complications.

D. Organizing a program to promote skateboard safety: This is primary prevention, aiming to prevent injuries associated with skateboarding by teaching safe practices before accidents happen. It targets a behavior to prevent harm.

E. Lobbying for funding for health promotion efforts: This supports primary prevention. By securing resources for health promotion, the nurse is contributing to initiatives that aim to prevent illness and promote well-being across the school community before health problems arise.

A. Decreased nausea B. Decreased manifestations of menopause C. Decreased manifestations of allergy D. Decreased eczema

Correct Answer is A

Explanation

A. Decreased nausea: Ginger is well-documented for its antiemetic properties. It helps relieve various types of nausea, including that caused by motion sickness, pregnancy, chemotherapy, and postoperative recovery by acting on the gastrointestinal tract and central nervous system.

B. Decreased manifestations of menopause: While some herbal remedies like black cohosh or soy are used for menopausal symptoms, ginger is not commonly used for hot flashes or hormonal regulation, so this would not be an appropriate indicator of its effectiveness.

C. Decreased manifestations of allergy: There is limited evidence suggesting that ginger plays a significant role in alleviating allergic symptoms. It is not considered a primary alternative therapy for allergy treatment.

D. Decreased eczema: Ginger does not have recognized therapeutic value for eczema. Other topical treatments or dietary interventions are more commonly used for managing this skin condition.

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A community health nurse is triaging clients following a worksite explosion. Exhibits Select the 2 clients that the nurse should identify as requiring immediate care.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A school nurse is planning primary prevention activities for the new school year. Which of the following should the nurse include? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse is evaluating a client who uses ginger as an alternative and complementary therapy. Which of the following outcomes indicates the effectiveness of the treatment?

Correct Answer is A

Explanation

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A community health nurse is triaging clients following a worksite explosion.

Exhibits
Select the 2 clients that the nurse should identify as requiring immediate care.