A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first?

Do not allow visiting of the victims until the bodies are prepared.

Provide privacy for law enforcement to interview the family.

Provide a calm location for the family to cope and discuss needs.

Call the hospital chaplain to stay with the family and pray for the deceased.

Answer and Explanation

The Correct Answer is C

Choice A reason: Restricting visiting of the victims until the bodies are prepared is a procedural step that can be managed without immediate involvement. While it's important, it does not directly address the family's immediate emotional needs.

Choice B reason: Providing privacy for law enforcement to interview the family is necessary for the investigation, but it should not take precedence over addressing the family's immediate emotional distress.

Choice C reason: Offering a calm location for the family to cope and discuss their needs addresses the immediate emotional and psychological support that the family requires in the wake of a traumatic event. It provides them with a safe space to begin processing their grief and start the healing process.

Choice D reason: Calling the hospital chaplain is a valuable step for providing spiritual and emotional support, but the first priority is to offer a calm and safe environment for the family. The chaplain can then be called to assist in this supportive space.

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Correct Answer is C

Explanation

Choice A reason: The black category in the START triage system is for clients who are deceased or have injuries so severe that they are not expected to survive even with immediate medical intervention. This client is not in that category since they are conscious and breathing.

Choice B reason: The green category is for clients who are ambulatory with minor injuries and do not require urgent medical attention. This client is experiencing significant respiratory distress, which categorizes them as more urgent.

Choice C reason: The red category is for clients who need immediate life-saving intervention. This client's respiratory rate of 36 and shortness of breath indicate a severe respiratory distress that requires urgent medical attention.

Choice D reason: The yellow category is for clients who are unable to walk but have stable conditions that do not require immediate life-saving intervention. This client's condition is more severe and needs prompt intervention.

A. Heart rate of 104 bpm B. Tympanic temperature of 102.6°F (39.2°C) C. Blood pressure of 158/90 mmHg D. Respiratory rate of 24 breaths/min

Correct Answer is B

Explanation

Choice A reason: A heart rate of 104 bpm can be expected in a client with pneumonia and after suctioning. Tachycardia (elevated heart rate) can occur as a response to infection, stress, or the suctioning procedure itself. While it should be monitored, it is not the most critical finding.

Choice B reason: A tympanic temperature of 102.6°F (39.2°C) is unexpected and indicates a significant fever, which may suggest a worsening infection or sepsis. This finding requires immediate attention as it could indicate that the current treatment for pneumonia is not effective, and the client's condition may be deteriorating.

Choice C reason: A blood pressure of 158/90 mmHg, though elevated, may be less critical in the context of this client's condition. Hypertension can occur due to various factors, including stress and illness, and should be monitored but is not the most urgent priority compared to a high fever.

Choice D reason: A respiratory rate of 24 breaths/min is slightly elevated but can be expected in a client with pneumonia and after suctioning. This rate indicates mild tachypnea, which should be monitored but is not as immediately concerning as a high fever.

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A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is assessing a mechanically ventilated client with pneumonia after providing deep oral suctioning to the client. Which assessment finding would be unexpected and be a priority for the nurse to address?

Correct Answer is B

Explanation

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