The nurse is triaging a group of clients in the emergency department. Which client should be assessed first?
A client with a burn on their forearm sustained from boiling water
A client with a right ankle fracture unable to place any weight on it
A client with severe abdominal pain who is pale and diaphoretic
A client with a head laceration being controlled with pressure
The Correct Answer is C
A. A client with a burn on their forearm sustained from boiling water: While burns require assessment and care, a forearm burn without signs of systemic compromise is not immediately life-threatening and can wait after more urgent cases.
B. A client with a right ankle fracture unable to place any weight on it: An isolated fracture causes pain and limited mobility but is not life-threatening, making it lower priority in triage compared to clients with potential systemic compromise.
C. A client with severe abdominal pain who is pale and diaphoretic: Pallor and diaphoresis indicate possible shock or serious internal pathology. This client is at highest risk for rapid deterioration and requires immediate assessment and intervention.
D. A client with a head laceration being controlled with pressure: If bleeding is controlled and the client is stable, this is urgent but not immediately life-threatening, so the client can be assessed after those showing signs of shock or systemic compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Palpation: Palpation involves using the hands and fingers to feel for texture, size, temperature, tenderness, and masses, rather than tapping to produce sounds.
B. Percussion: Percussion uses short, sharp tapping motions on the surface of the body to produce sounds or vibrations. These sounds help the nurse assess the density, location, and size of underlying organs and structures.
C. Inspection: Inspection involves visually observing the client’s body, posture, skin, and movements, without the use of touch or tapping techniques.
D. Auscultation: Auscultation involves listening to internal body sounds, typically with a stethoscope, such as heart, lung, and bowel sounds. It does not involve tapping or assessing tissue density.
Correct Answer is A
Explanation
A. Mood: Behavioral assessment during the general survey involves observing the client’s affect, emotional state, and overall behavior. Evaluating mood helps the nurse understand how the client is coping, their level of emotional stability, and any signs of anxiety, depression, or distress. It provides insight into psychological and emotional well-being, which is essential for holistic care planning.
B. Age: Age is a component of the general survey that falls under physical characteristics rather than behavior. It helps establish baseline expectations for growth, development, and age-appropriate functioning, but it does not provide information about the client’s emotional state or behavior.
C. Posture: Posture is part of the physical appearance assessment within the general survey. It provides information about musculoskeletal health, possible pain, or functional limitations but does not reflect the client’s behavioral or emotional status.
D. Gait: Gait assessment evaluates how a client moves, including balance, coordination, and mobility. While it offers important physical and neurological information, it does not give direct insight into the client’s mood, affect, or behavioral patterns.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.