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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.

A.

Client 1

B.

Client 2

C.

Client 3

D.

Client 4

E.

Client 5

F.

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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Related Questions

Correct Answer is D

Explanation

A. Identify the client's spoken dialect: Knowing the specific dialect is important for selecting an appropriate interpreter, but this should be done after securing access to interpretation services. It is a secondary step following the identification of the communication barrier.

B. Document the use of the interpreter: Documentation is a necessary legal and clinical step after care has been provided. It confirms communication occurred appropriately but is not the first priority when initiating communication.

C. Talk directly to the client: While it is respectful and essential to engage with the client directly once interpretation is arranged, doing so without an interpreter risks miscommunication and may compromise informed consent and care quality.

D. Contact a qualified medical interpreter: The first action is to ensure accurate communication by accessing a trained medical interpreter. This ensures the client receives information in a language they understand, which is critical for safe and effective care.

Correct Answer is B

Explanation

A. "I really hope that I can live another 2 weeks, so I can see my child graduate high school." This statement expresses a hopeful and realistic goal reflecting emotional coping with the terminal illness. It does not necessarily indicate a need for social work referral.

B. "I don't have health insurance, and now I am leaving my family with such a mess." Concerns about financial issues and lack of health insurance suggest the client may need assistance with resources, financial planning, or accessing support services, which falls within the social worker’s role.

C. "I am so proud of my child who promised to step up and help my spouse after I am gone." This statement reflects pride and positive family support, indicating emotional coping rather than a need for social work referral.

D. "I am angry and cannot believe this is happening to me at such a young age." Expressing anger is a common emotional response to terminal illness and can be addressed through nursing support and counseling; it does not automatically require social work involvement.

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