A nurse is assisting with triage for group of clients following a mass casualty incident. Which of the following actions should the nurse take?
Check blood pressure for a client who is short of breath.
Identify arterial bleeding by the presence of dark red blood.
Open the airway of a client who has a cervical injury by using the jaw-thrust technique.
Request the assistance of another staff member to log roll a client.
The Correct Answer is C
A) Check blood pressure for a client who is short of breath:
In a mass casualty incident, triage prioritizes addressing life-threatening conditions first. While shortness of breath may indicate a serious problem, assessing blood pressure would not be the most immediate action. The nurse should focus on airway, breathing, and circulation (the ABCs) before checking vital signs like blood pressure, as these could indicate the need for more urgent interventions.
B) Identify arterial bleeding by the presence of dark red blood:
Arterial bleeding is typically characterized by bright red blood that spurts or pulses with the heartbeat. Dark red blood is more indicative of venous bleeding. Recognizing arterial bleeding involves identifying the bright red, spurting blood, not dark red blood. It is essential to address major bleeding immediately by applying pressure or using a tourniquet as needed.
C) Open the airway of a client who has a cervical injury by using the jaw-thrust technique:
In clients with potential cervical spine injuries, the jaw-thrust technique is the recommended method to open the airway, as it does not involve tilting the head and neck, which could exacerbate a cervical injury. Ensuring the airway is patent is a priority in triage, and the jaw-thrust maneuver minimizes the risk of further injury to the spine.
D) Request the assistance of another staff member to log roll a client:
While log rolling is important for proper spinal alignment in clients with suspected spinal injuries, it is not the most urgent action during triage. In the context of a mass casualty incident, other immediate interventions, such as securing the airway and controlling bleeding, should take precedence before moving the patient unless the client’s condition requires repositioning to facilitate life-saving care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) "Our child has a better grasp of reality":
While methylphenidate can improve focus and reduce impulsivity in children with ADHD, a "better grasp of reality" is not a typical or direct effect of the medication. The goal of medication like methylphenidate is to manage symptoms of ADHD, such as inattention, hyperactivity, and impulsivity, rather than altering the child's sense of reality. Therefore, this statement does not reflect an expected outcome of the medication.
B) "Our child has lost some weight since his last appointment":
Weight loss can be a side effect of methylphenidate, as it may reduce appetite. However, this is not an indication that the medication is effective in managing ADHD symptoms. A decrease in weight does not correlate with the desired effects of improved concentration or behavior control. In fact, parents should be educated on monitoring the child’s nutritional intake and discussing any concerns about weight loss with the healthcare provider.
C) "Our child has increased his daily caloric intake":
While it is beneficial for children taking methylphenidate to maintain adequate nutrition, an increase in caloric intake is not directly related to the medication’s effectiveness in treating ADHD. The goal is to improve symptoms of inattention, hyperactivity, and impulsivity, not to focus on changes in food consumption.
D) "Our child is able to complete his homework on time":
This statement is a clear indicator that methylphenidate is working effectively. One of the main goals of treating ADHD is to improve the child's ability to focus and complete tasks, such as homework, within a reasonable time frame. The child being able to complete homework on time reflects the positive effect of the medication in improving concentration, attention, and task completion.
Correct Answer is B
Explanation
A) Social withdrawal: While social withdrawal can be a sign of depression or a worsening cognitive decline in clients with Alzheimer's disease, it does not immediately threaten the client's safety. It is important to monitor and address, but it is not the priority concern that requires immediate intervention.
B) Wandering outside at night: This is the priority issue and requires immediate intervention. Wandering, especially at night, poses a significant safety risk to clients with Alzheimer's disease. The client may become lost, disoriented, or fall, leading to injury. Immediate steps should be taken to ensure the environment is safe, such as installing locks or alarms on doors, and potentially seeking further evaluation or care interventions to manage this behavior.
C) Difficulty articulating words: Difficulty with speech or articulation can occur as part of Alzheimer's disease, especially in the later stages. While it can be distressing for the client and family, it does not present an immediate threat to the client's safety. This issue should be addressed as part of the overall care plan, but it is not as urgent as wandering.
D) Inability to remember their partner's name: Memory loss, including difficulty remembering names, is a common symptom of Alzheimer's disease. While it can be emotionally difficult for both the client and their family, it does not pose an immediate risk to the client’s safety or well-being. This symptom should be monitored, but it is not the top priority for immediate intervention.
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