A nurse is assisting with triaging clients after a mass casualty event. Which of the following clients should the nurse attend to first?
A client who has a splinted open fracture of the left medial malleolus.
A client who has a penetrating head injury and is experiencing seizures.
A client who has severe respiratory stridor and a deviated trachea.
A client who has a small circular partial-thickness burn of the left calf.
The Correct Answer is C
Choice A reason: An open fracture, while needing medical attention, is not immediately life-threatening. The client's condition is stable enough to wait while more critical cases are attended to.
Choice B reason: A penetrating head injury with seizures is a critical condition. However, ensuring a patent airway takes precedence in emergency situations. This client's seizures indicate serious brain injury, but the immediate threat to life, such as airway obstruction, must be prioritized.
Choice C reason: Severe respiratory stridor and a deviated trachea indicate a life-threatening airway obstruction. This client needs immediate attention to secure the airway and prevent respiratory failure. This is the highest priority because without a clear airway, the client will not survive long enough to benefit from other interventions.
Choice D reason: A partial-thickness burn, although painful and requiring treatment, is not immediately life-threatening. This client can safely wait while those with more critical needs are attended to.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Osteoarthritis is a degenerative joint disease and is not associated with SIADH. It does not typically affect the body's regulation of antidiuretic hormone (ADH) or fluid balance.
Choice B reason: Lung cancer, particularly small cell lung cancer, is a common cause of SIADH. Tumor cells can produce and secrete ADH, leading to inappropriate water retention and hyponatremia. Therefore, asking about lung cancer history is important in the assessment.
Choice C reason: The correct answer is c because liver cirrhosis can lead to secondary conditions that may affect fluid balance and ADH secretion. Although not a direct cause of SIADH, liver dysfunction can complicate the clinical picture and contribute to fluid retention issues.
Choice D reason: Dyspepsia, or indigestion, is not related to SIADH and does not typically impact ADH regulation. It is a gastrointestinal issue that does not affect fluid balance.
Choice E reason: The correct answer is e because seizures can be associated with conditions that trigger SIADH. Neurological disorders, including brain injuries and infections, can lead to the inappropriate release of ADH, resulting in fluid retention and hyponatremia.
Correct Answer is B
Explanation
Choice A reason: While a healthy diet is important, avoiding fried foods alone is not sufficient for managing hepatitis A. This statement does not fully address the necessary precautions to prevent transmission.
Choice B reason: The correct answer is b because abstaining from sexual intercourse is essential to prevent the spread of hepatitis A. The virus can be transmitted through close personal contact, including sexual activity.
Choice C reason: Refraining from international travel may be advisable in some cases, but it is not a specific requirement for managing hepatitis A. This statement does not directly address transmission prevention.
Choice D reason: Avoiding salads in restaurants can help reduce the risk of foodborne transmission of hepatitis A, but it is not as comprehensive as abstaining from sexual intercourse, which directly prevents person-to-person transmission.
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