A nurse is educating nursing students on the importance of client-centered community-based care. The nurse understands that which of the following principles is most essential to client-centered, community-based care in nursing?

Choice A reason:

Inserting a padded tongue blade into the client’s mouth is not recommended and can be dangerous. During a seizure, there is a risk of causing injury to the client’s mouth or teeth, and it can also obstruct the airway. The correct approach is to ensure the client’s safety by preventing injury, not by inserting objects into their mouth.

Choice B reason:

Restraining the client during a seizure is not advised. Restraints can cause additional harm and do not prevent the seizure from occurring. Instead, the focus should be on protecting the client from injury by ensuring a safe environment and allowing the seizure to run its course.

Choice C reason:

Moving objects away from the client is a crucial step in ensuring their safety during a seizure. This action helps prevent the client from hitting or injuring themselves on nearby objects. Creating a safe space around the client is one of the primary goals during a seizure to minimize the risk of injury.

Choice D reason:

Placing the client on their back is not recommended during a seizure. Instead, the client should be placed on their side if possible, to help keep the airway clear and reduce the risk of aspiration. This position also allows for better monitoring of the client’s breathing and overall condition.

Choice A: Red tag

A red tag is assigned to patients who require immediate medical attention and intervention to survive. These patients have life-threatening injuries but have a high chance of survival if treated promptly. In this scenario, the client has a respiratory rate of 38, a weak and rapid pulse, and uncontrolled bleeding. These symptoms indicate severe physiological distress and potential shock, necessitating immediate intervention to prevent death. According to NATO triage guidelines, such critical conditions warrant a red tag to prioritize urgent care1.

Choice B: Black tag

A black tag is used for patients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. This category is also known as “expectant” and is used to allocate resources to those with a higher chance of survival. The client in this scenario, despite having severe symptoms, is not described as being beyond the possibility of survival, thus a black tag would not be appropriate1.

Choice C: Green tag

A green tag is assigned to patients with minor injuries who can wait for medical treatment without immediate risk to life. These patients are often referred to as “walking wounded.” The client’s symptoms of a high respiratory rate, weak and rapid pulse, and uncontrolled bleeding are far too severe to be classified under this category. Assigning a green tag would delay critical care, potentially leading to fatal outcomes1.

Choice D: Yellow tag

A yellow tag is for patients who have serious injuries but whose treatment can be delayed without immediate risk to life. These patients need medical attention but are stable enough to wait for a short period. Given the client’s symptoms, particularly the uncontrolled bleeding and signs of shock, delaying treatment could result in rapid deterioration. Therefore, a yellow tag would not be suitable in this case1.