An emergency department nurse triages a group of school children injured in a school bus crash. Which of the following children should the nurse have the provider evaluate first?
A child who has a forehead wound that is bleeding copiously
A child who has a compound fracture of the femur and is crying in pain
A child who reports diplopia and nausea and was unconscious at the scene but is now awake
A child who has several missing permanent teeth and a swollen, ecchymotic upper lip
The Correct Answer is C
A. A child who has a forehead wound that is bleeding copiously: While bleeding wounds require attention, they are not immediately life-threatening compared to other injuries described.
B. A child who has a compound fracture of the femur and is crying in pain: While painful, a
femur fracture is not typically immediately life-threatening unless it is causing severe bleeding or compromising circulation.
C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake:
These symptoms suggest potential head trauma and require urgent evaluation to assess for intracranial injuries.
D. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip: These injuries, while concerning, are not immediately life-threatening compared to the potential head injury described in option C.
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Related Questions
Correct Answer is D
Explanation
A. Povidone-iodine may be used as a wound cleanser, but the method described here (using cotton balls) is not typically recommended as it can leave fibers in the wound.
B. Administering oral analgesia prior to wound irrigation may be appropriate for pain management but is not directly related to understanding wound irrigation technique.
C. Warming irrigation solution in a microwave oven can lead to uneven heating and potential tissue damage. This method is not recommended for warming irrigation solution.
D. Irrigating the wound from the top to the bottom ensures that contaminants are flushed away from the wound site, reducing the risk of infection and promoting healing. This indicates an understanding of proper wound irrigation technique.
Correct Answer is A
Explanation
A.
A. Visible contusions on all four extremities may indicate physical abuse, especially in the context of being brought to the emergency department by a family member. Reporting the
incident to Adult Protective Services is essential to ensure the safety and well-being of the client.
B. Interviewing the client with his adult child present may not be appropriate if there are concerns about potential abuse or coercion.
C. Forcing the client to answer every assessment question may not be appropriate if the client is in distress or unable to communicate freely.
D. Advising the client to consult a social worker may be appropriate, but reporting suspected abuse to Adult Protective Services is the priority action in this situation.
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