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A nurse in the emergency department (ED) is triaging four clients following a mass casualty event. The nurse should identify which of the following clients as emergent?

A.

A client who has a leg and ankle fracture

B.

A client who reports flank pain radiating to the groin

C.

A client who has a raised red rash on the abdomen

D.

A client who has expiratory stridor

Answer and Explanation

The Correct Answer is D

A. A leg and ankle fracture is serious but typically not life-threatening compared to issues involving airway obstruction or severe bleeding.
B. Flank pain radiating to the groin may indicate a kidney stone or other condition, but it is less urgent than airway obstruction.
C. A raised red rash on the abdomen could be a sign of a less urgent condition, such as a viral infection or allergic reaction, and does not require immediate intervention compared to respiratory distress.
D. Expiratory stridor indicates upper airway obstruction or severe respiratory distress, which is a life-threatening condition requiring immediate intervention. Stridor suggests possible airway compromise, which needs to be addressed urgently to prevent respiratory failure.
 


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Related Questions

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"E"}

Explanation

Pneumonia: The client is at risk for pneumonia due to decreased lung expansion and increased risk of aspiration, especially after abdominal surgery.

Deep vein thrombosis (DVT): The client is at risk for DVT due to prolonged immobility and the increased risk of blood clots associated with surgery.

Urinary retention: The Foley catheter may interfere with the client's ability to void normally, increasing the risk of urinary retention.

Correct Answer is A

Explanation

A. A decrease in the Glasgow Coma Scale score from 13 to 10 indicates a significant change in consciousness and may suggest worsening of the brain injury. This is a critical sign that requires immediate reporting and evaluation.
B. Diplopia (double vision) can be a concerning symptom, but it is not as immediately critical as a significant change in the Glasgow Coma Scale score. It still warrants attention but may not be the highest priority.
C. Ataxia (lack of voluntary coordination of muscle movements) is a serious symptom that could indicate worsening of the brain injury but is not as immediately critical as a significant change in the Glasgow Coma Scale score.
D. A drop in heart rate from 76 to 70/min is generally not significant in the context of mild TBI. Changes in heart rate are less critical compared to changes in the level of consciousness.

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