The emergency department triage nurse receives notification there has been a mass shooting incident at a local shopping mall with several casualties injured. The hospital’s emergency response plan is initiated. Which client should the nurse prioritize for care?
Client with a sucking chest wound, conscious, blood pressure 88/58 mm Hg, heart rate 115/min, and red tag observed.
Client with a significant penetrating head wound, unconscious with irregular breathing pattern, and black tag observed.
Client with superficial lacerations to the left arm and left lower leg.
Client with closed left lower leg injury, air cast in place, pain reported as 9 on a 0 to 10 numeric pain scale.
The Correct Answer is A
Choice A rationale
A sucking chest wound compromises breathing, causes tension pneumothorax, and decreases cardiac output. Hypotension (88/58 mm Hg) and tachycardia (115/min) indicate shock, warranting immediate intervention. Red tag signifies life-threatening but potentially survivable injuries.
Choice B rationale
Penetrating head wounds with irregular breathing suggest brainstem injury, poor prognosis, and impending death. Black tag indicates un-survivable injuries, prioritizing resource allocation to others with a better survival potential.
Choice C rationale
Superficial lacerations involve minor soft tissue damage that does not compromise vital functions. These injuries are non-life-threatening and can wait for delayed medical care without significant risk to life or function.
Choice D rationale
Closed lower leg injuries cause localized pain but do not compromise airway, breathing, or circulation. Pain severity does not indicate life-threatening harm, allowing delayed care. Yellow tag signifies urgent but not immediate need for treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Papules are raised, firm skin lesions often exceeding 0.5 cm in diameter. They are palpable and represent conditions such as warts or skin tags, differing from nonpalpable lesions described.
Choice B rationale
Vesicles are fluid-filled lesions with a diameter of less than 0.5 cm. They are palpable and typically associated with disorders like herpes simplex, not fitting the client's description.
Choice C rationale
Nodules are solid, elevated skin lesions larger than 0.5 cm in diameter. Unlike the client’s lesion, nodules extend into the dermis or subcutaneous layer, which makes them distinguishable.
Choice D rationale
Macules are flat, nonpalpable lesions less than 0.5 cm in diameter. They are confined to the epidermis, and examples include freckles or petechiae, matching the given characteristics precisely.
Correct Answer is D
Explanation
Choice A rationale
Suggesting that the situation will improve over time lacks therapeutic value and may dismiss the client’s current emotions, failing to provide active emotional support or promote coping mechanisms.
Choice B rationale
Acknowledging the difficulty of the situation validates the client’s feelings but does not encourage engagement in active coping strategies or provide constructive emotional assistance.
Choice C rationale
Recommending talking to a chaplain assumes the client’s preference for spiritual support without addressing their immediate concerns or fostering problem-solving and emotional expression.
Choice D rationale
Encouraging the client to reflect on past coping mechanisms promotes problem-solving, emotional expression, and the utilization of effective strategies previously used, fostering therapeutic engagement and resilience.
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