An emergency room nurse is triaging victims of a mass-casualty event. Which client should receive care first?

A 30-year-old distraught mother holding her crying child

A 65-year-old conscious male with a head laceration

A 48-year-old with a simple fracture of the lower leg

A 26-year-old male who has pale, cool, clammy skin

Answer and Explanation

The Correct Answer is D

A. A 30-year-old distraught mother holding her crying child: While the mother is distraught, her condition does not appear life-threatening. This client should be triaged to a lower priority compared to those with immediate medical needs.

B. A 65-year-old conscious male with a head laceration: A head laceration in a conscious client is concerning but not immediately life-threatening unless there are signs of more serious brain injury (e.g increased intracranial pressure). This client would be triaged as urgent, not emergent.

C. A 48-year-old with a simple fracture of the lower leg: A simple fracture is painful but does not typically threaten life or limb. This client is categorized as urgent but not emergent compared to others with more critical needs.

D. A 26-year-old male who has pale, cool, clammy skin: This client is showing signs of shock, which is a medical emergency. Pale, cool, and clammy skin suggests hypoperfusion, potentially due to hemorrhage, dehydration, or trauma. This client requires immediate intervention to restore circulation and prevent further deterioration.

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Correct Answer is C

Explanation

A. Amnesia: Amnesia can occur with traumatic brain injury but is not a specific indicator of increased ICP. Memory loss may result from the injury itself rather than a change in intracranial pressure.

B. Tachycardia: Tachycardia can occur in response to stress or pain but is not typically a primary sign of increased ICP. Increased ICP often results in bradycardia rather than tachycardia as the body's compensatory response.

C. Restlessness: Restlessness is a common early sign of increased ICP, as the brain becomes increasingly unable to maintain normal functions due to pressure. This agitation is often one of the first symptoms before more severe changes in consciousness or vital signs occur.

D. Hypotension: Hypotension is not a primary sign of increased ICP. Increased ICP often leads to hypertension as a compensatory mechanism to maintain cerebral perfusion pressure. Hypotension may occur later in severe cases but is not an early sign.

A. Inspect the mouth for signs of inhalation injuries B. Administer intravenous pain medication C. Insert an indwelling urinary catheter D. Draw blood for a complete blood cell (CBC) count

Correct Answer is A

Explanation

A. Inspect the mouth for signs of inhalation injuries: The priority action for a client with burns, especially facial burns is to assess for potential inhalation injuries. Inhalation of hot gases or smoke can cause damage to the airways, leading to swelling, obstruction, and respiratory distress.

B. Administer intravenous pain medication: Pain management is important, but it is not the immediate priority. Ensuring the client’s airway is protected and that there are no life-threatening respiratory complications takes precedence over pain relief in the early stages of burn care.

C. Insert an indwelling urinary catheter: Inserting a urinary catheter is typically done for monitoring urine output in burn patients, especially if there is concern for fluid resuscitation needs. However, it is not the priority. Assessing for respiratory injury should come first.

D. Draw blood for a complete blood cell (CBC) count: While a CBC can provide useful information, such as signs of infection or anemia, it is not the priority action. The immediate priority is ensuring the airway is safe and free of inhalation injury, as respiratory compromise can lead to rapid deterioration.

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An emergency room nurse is triaging victims of a mass-casualty event. Which client should receive care first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an Indication of increased intracranial pressure (ICP)?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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