A nurse has been assigned to an internal disaster drill team and is triaging clients. Which of the following clients should the nurse classify with a green tag?
A client who has multiple facial lacerations.
A client who has a puncture wound in the right lower lung.
A client who has full-thickness burns over the lower extremities.
A client who has an open compound fracture of the humerus.
The Correct Answer is A
Choice A reason: Multiple facial lacerations, if not affecting airway or causing severe bleeding, are minor injuries in triage (green tag). These clients can wait for treatment without immediate risk, aligning with disaster triage principles, making this the correct classification.
Choice B reason: A puncture wound to the lung is life-threatening, potentially causing pneumothorax or hemothorax, requiring urgent intervention (red tag). This is not a minor injury, so it does not qualify for a green tag, making it incorrect.
Choice C reason: Full-thickness burns over the lower extremities are severe, requiring immediate fluid resuscitation and specialized care (red or yellow tag). These are not minor injuries, so this client does not fit green tag criteria, making it incorrect.
Choice D reason: An open compound fracture of the humerus is a significant injury with risks of infection and bleeding, requiring prompt surgical intervention (yellow or red tag). It is not minor, so it does not qualify for a green tag, making it incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Experiencing delusions can contribute to agitation, but it is not the strongest predictor of violence. Delusions may lead to unpredictable behavior, but past actions are more reliable indicators, so this factor is less definitive, making it incorrect.
Choice B reason: A history of being in prison indicates past legal issues but not necessarily violent behavior. Incarceration alone is not a direct predictor of future violence, so this factor is less reliable than actual violent history, making it incorrect.
Choice C reason: A history of violent behavior is the best predictor of future violence, as past actions strongly correlate with recurrence, per evidence-based risk assessments. This reliable indicator guides safety planning, making it the correct factor to emphasize in teaching.
Choice D reason: Substance use disorder increases impulsivity and aggression risk, but it is less predictive than a documented history of violence. Substance use is a contributing factor, not the strongest indicator, so this is incorrect compared to past behavior.
Correct Answer is ["B","C"]
Explanation
Choice A reason: Telling the daughter not to worry dismisses her emotional concerns and does not facilitate open communication. Addressing fears about a loved one’s death requires empathy and discussion to process grief and understand hospice care, which focuses on comfort. This response is inappropriate, as it avoids addressing the daughter’s needs.
Choice B reason: Acknowledging the daughter’s concerns about her mother’s death and inviting discussion is therapeutic. It validates her emotions, encouraging open dialogue about grief, hospice care, and end-of-life expectations. This approach supports psychological coping, aligns with palliative care principles, and helps the daughter prepare for her mother’s transition, making it appropriate.
Choice C reason: Discussing the mother’s cancer and its implications helps the daughter understand the disease progression and hospice care’s role in symptom management. This fosters informed communication, addressing fears and clarifying expectations. It supports emotional preparation for end-of-life discussions, making this response appropriate for facilitating understanding and coping.
Choice D reason: Encouraging the daughter to avoid thinking about dying dismisses the reality of the situation and hinders emotional processing. Hospice care involves preparing for end-of-life, and open discussions about death are therapeutic. This response is inappropriate, as it discourages necessary conversations about the mother’s condition and prognosis.
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