The nurse is triaging victims of a tornado at an emergency shelter. An adult who has been wandering and crying comes to the nurse. Which action should the nurse take?
Check the client’s temperature, blood sugar, and urine output.
Arrange for the client to be transported for laboratory tests and an electrocardiogram (ECG).
Delegate care of the crying client to an unlicensed assistant.
Direct the client to the shelter’s nutrition center to obtain water and food.
The Correct Answer is D
Answer and explanation
The correct answer is Choice D.
Choice A rationale
Checking the client’s temperature, blood sugar, and urine output could be important in certain situations, but in this case, it may not be the most immediate need. The client is wandering and crying, which suggests emotional distress rather than a physical health issue.
Choice B rationale
Arranging for the client to be transported for laboratory tests and an electrocardiogram (ECG) would be an overreaction in this situation. There’s no indication from the client’s behavior that they are experiencing a medical emergency.
Choice C rationale
Delegating care of the crying client to an unlicensed assistant is not the best choice. The client is likely experiencing emotional distress due to the traumatic event, and they would benefit from the care and attention of a trained professional.
Choice D rationale
Directing the client to the shelter’s nutrition center to obtain water and food is the best action in this situation. The client may be dehydrated or hungry, which could be contributing to their distress. Providing for these basic needs can help to calm the client and provide a sense of safety and stability.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer and explanation The correct answer is D. Choice A rationale
Staying with someone for 10 hours post-injection is not a standard recommendation after receiving the Hepatitis B Vaccine (HBV). The vaccine is generally well-tolerated, and serious side effects are rare.
Choice B rationale
While it can be comforting to have a family member present during medical procedures, it is not necessary for the final injection of the HBV series.
Choice C rationale
While it is important to encourage vaccination among all eligible individuals, the immediate concern after healthcare workers receive the HBV is not about their family members’ vaccination status.
Choice D rationale
Regular monitoring of immunization levels is important after receiving the HBV series. This is because healthcare workers are at a higher risk of exposure to Hepatitis B, and ensuring immunity is crucial for their safety.
Correct Answer is D
Explanation
Answer and explanation
The correct answer is Choice D.
Choice A rationale
Converting written vehicle instructions into a pictorial format can help improve understanding, but it does not directly address the physical dangers associated with the machinery.
Choice B rationale
Educating farm workers not to smoke around farm equipment can prevent fires, but it does not directly reduce the risk of machinery-related injuries.
Choice C rationale
Offering rehabilitation services to injured farm workers is important, but it is a reactive measure. The goal should be to prevent injuries from occurring in the first place.
Choice D rationale
Collaborating with lawmakers to mandate safe tractor design can have a significant impact on reducing farm machinery injuries. By addressing the issue at the design level, many injuries can be prevented.
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