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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 {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

A high white blood cell (WBC) count in cerebrospinal fluid (CSF) is more commonly associated with bacterial meningitis, characterized by a high neutrophil count, low glucose, and high protein levels. it is also seen in encephalitis and reflects the individual cell lines that are affected.

Muscle weakness and altered levels of consciousness can occur in both conditions but are more prominent in encephalitis, which often presents with focal neurological deficits and seizures. The

Kernig sign, a classical sign of meningitis, is a physical examination finding that indicates irritation of the meninges and supports a diagnosis of bacterial meningitis when positive.

An elevated body temperature is common in bacterial meningitis, but it is not exclusive and can be observed in encephalitis as well.

Correct Answer is B

Explanation

A. Checking the IV site for bleeding is important but should be done more frequently in a client with thrombocytopenia (low platelet count), as bleeding can occur unexpectedly.
B. Administering stool softeners is a key intervention for clients with thrombocytopenia, as it helps to prevent straining during bowel movements, which could cause rectal bleeding due to fragile blood vessels.
C. Checking for proteinuria is not directly related to thrombocytopenia or the risk of bleeding. It is more commonly associated with kidney function monitoring.
D. Obtaining body temperature readings is important for infection monitoring, but it does not directly address the risk associated with a low platelet count, which primarily concerns bleeding.

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