A school nurse is helping emergency medical services (EMS) triage students after a bus accident occurred in the school parking lot. A 10-year-old client is awake, alert, and ambulatory but reports a headache and neck pain. Using START triage, what acuity level would be assigned to this client?
Red
Green
Black
Yellow
The Correct Answer is D
Choice A reason: The red category in START triage is reserved for clients who need immediate intervention to survive. This includes those with life-threatening injuries such as severe bleeding or airway obstruction. In this scenario, the 10-year-old client is awake, alert, and ambulatory, indicating that their condition is not immediately life-threatening. Therefore, the red category is not applicable.
Choice B reason: The green category is used for clients who are able to walk and have minor injuries. While the 10-year-old client is ambulatory, the presence of a headache and neck pain suggests that their injuries might be more severe than minor. The green category would not be appropriate because their symptoms indicate a need for further evaluation and monitoring.
Choice C reason: The black category is assigned to clients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. The 10-year-old client is awake, alert, and able to walk, which clearly does not align with the criteria for the black category. Therefore, this category is not suitable for the client's condition.
Choice D reason: The yellow category in START triage is for clients who require medical attention but their injuries are not immediately life-threatening. Given that the 10-year-old client is reporting a headache and neck pain, there is a potential risk of underlying injury that warrants attention but does not require immediate intervention. Thus, the yellow category is the most appropriate acuity level for this client.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A reason: The person granted power of attorney for healthcare would be responsible for signing the informed consent only if the client is unable to make decisions for themselves due to incompetence or incapacity. Since the client in this scenario is competent and neurologically intact, the power of attorney is not applicable.
Choice B reason: The client's emergency contact is not authorized to sign informed consent unless they hold legal power of attorney or the client is incapacitated and unable to make decisions. The emergency contact's primary role is to be contacted in emergency situations, not to make medical decisions on behalf of the client.
Choice C reason: The legal next of kin would only be responsible for signing the informed consent if the client is not capable of doing so themselves. In this case, the client is competent and neurologically intact, so the next of kin's consent is not needed.
Choice D reason: The client is responsible for signing the informed consent because they are competent and capable of making their own medical decisions. Informed consent must be obtained from the client directly when they have the capacity to understand and agree to the proposed treatment or procedure.
Correct Answer is D
Explanation
Choice A reason: Veracity is the principle of truthfulness and honesty. It involves providing accurate information to clients and being truthful in communication. While important in healthcare, veracity does not specifically address the nurse's failure to ensure the client's safety after administering a narcotic.
Choice B reason: Autonomy refers to respecting the client's right to make their own decisions about their care. While autonomy is a fundamental ethical principle, the scenario involves the nurse's responsibility to ensure safety, which falls under a different principle.
Choice C reason: Beneficence is the principle of acting in the best interest of the client by promoting good and preventing harm. Although related to the scenario, beneficence focuses more on the proactive aspect of providing care rather than preventing harm resulting from inaction.
Choice D reason: Nonmaleficence is the ethical principle of "do no harm." The nurse violated this principle by discharging the client without ensuring they had a designated driver, leading to a motor vehicle collision and injuries. The nurse's action indirectly caused harm, violating the principle of nonmaleficence.
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