A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first?
A client who has bipolar disorder and is exhibiting signs of hallucination
A client who has major burns over 75% of their body surface area
A client who has two open chest wounds with a left tracheal deviation
A client who has a neck injury and is unable to breathe spontaneously
The Correct Answer is D
Choice A reason: A client who has bipolar disorder and is exhibiting signs of hallucination is not the highest priority for treatment. The client may have a psychiatric emergency, but their condition is not life-threatening or unstable. The nurse should assess the client's safety and provide emotional support, but they can wait for further intervention.
Choice B reason: A client who has major burns over 75% of their body surface area is a high priority for treatment, but not the highest. The client has a serious injury that can cause shock, infection, and organ failure. The nurse should monitor the client's vital signs, fluid status, and wound care, but they can wait for a short time.
Choice C reason: A client who has two open chest wounds with a left tracheal deviation is a high priority for treatment, but not the highest. The client has a tension pneumothorax, which is a life-threatening condition that causes air to accumulate in the pleural space and compress the lung and the heart. The nurse should seal the wounds with an occlusive dressing and prepare for chest tube insertion, but they can wait for a few minutes.
Choice D reason: A client who has a neck injury and is unable to breathe spontaneously is the highest priority for treatment. The client has a respiratory emergency, which is the most urgent condition that requires immediate intervention. The nurse should establish an airway, provide oxygen, and stabilize the neck, as well as call for help and notify the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The client must understand the risks and benefits of the proposed treatment is not information that the nurse should include in the teaching about implied consent. This is information that the nurse should include in the teaching about informed consent, which is a type of consent that requires the client's written or verbal agreement after receiving adequate information about the treatment.
Choice B reason: The nurse's signature indicates that they witnessed the client's signature is not information that the nurse should include in the teaching about implied consent. This is information that the nurse should include in the teaching about informed consent, which is a type of consent that requires the client's written or verbal agreement after receiving adequate information about the treatment.
Choice C reason: Consent can be verbal or written is not information that the nurse should include in the teaching about implied consent. This is information that the nurse should include in the teaching about informed consent, which is a type of consent that requires the client's written or verbal agreement after receiving adequate information about the treatment.
Choice D reason: Nonverbal behavior indicates agreement is information that the nurse should include in the teaching about implied consent. This is a type of consent that does not require the client's written or verbal agreement, but is based on the client's actions or circumstances. For example, if the client holds out their arm for a blood pressure measurement, they are giving implied consent for the procedure.
Correct Answer is A
Explanation
Choice A reason: Providing the client with written information in their spoken language is the appropriate action for the nurse to take. This would ensure that the client understands the information and can refer to it later. It would also respect the client's culture and preferences.
Choice B reason: Speaking very slowly during the teaching session is not an appropriate action for the nurse to take. This would not improve the communication or comprehension of the client. It might also be perceived as patronizing or disrespectful by the client.
Choice C reason: Using medical terminology while explaining the medications is not an appropriate action for the nurse to take. This would confuse the client and hinder the learning process. The nurse should use simple and clear language that the client can understand.
Choice D reason: Having the client's family member who is present interpret is not an appropriate action for the nurse to take. This would compromise the accuracy and confidentiality of the information. It might also create a conflict of interest or a bias for the family member. The nurse should use a professional interpreter or a translation device if available.
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