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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer and explanation
The correct answer is Choice D.
Choice A rationale
Reviewing the child's medical history for any allergies or sensitivities is always a good practice during a routine check-up³?³?³?³?. However, in this case, the child's symptoms of difficulty focusing in school and decreased appetite may not necessarily be related to allergies or sensitivities. These symptoms could be indicative of various conditions, including emotional distress, sleep disorders, or other health issues²².
Choice B rationale
Examining the child's torso and arms for any signs of physical trauma is an important step if there is suspicion of physical abuse³?[^40^]?¹?². However, the symptoms described by the mother do not necessarily suggest physical trauma. Therefore, while a physical examination is part of a routine check-up, it may not directly address the child's reported symptoms.
Choice C rationale
Permethrin is a medication used to treat scabies and lice¹³¹?. There is no indication in the scenario provided that the child has these conditions. Therefore, advising the parents to initiate treatment with permethrin would not be appropriate based on the information given.
Choice D rationale
Given the child's symptoms of difficulty focusing in school and decreased appetite, it would be appropriate to recommend the parents to seek further medical evaluation for the child²?²?²?. These symptoms could be indicative of various conditions, including emotional distress, sleep disorders, or other health issues, which would require further investigation²².
Correct Answer is D
Explanation
Answer and explanation
The correct answer is Choice D.
Choice A rationale
Increasing physical activity is a key component of weight loss. It helps to burn calories, build muscle, and boost metabolism. However, physical activity alone may not be sufficient for weight loss. It’s also important to consider dietary habits.
Choice B rationale
Improving diet is another crucial aspect of weight loss. This can involve eating more fruits, vegetables, and whole grains, reducing the intake of processed foods and sugary drinks, and watching portion sizes. However, diet alone may not be enough for weight loss, and it’s also important to incorporate physical activity.
Choice C rationale
Reducing portion sizes can help to decrease calorie intake, which can contribute to weight loss. However, portion control alone may not lead to weight loss if the individual is not consuming a balanced diet or if they are not physically active.
Choice D rationale
All of the above strategies - increasing physical activity, improving diet, and reducing portion sizes - are important for weight loss. They work together to create a calorie deficit, which is necessary for weight loss. It’s also important to note that these strategies should be implemented as part of a sustainable lifestyle change, rather than a short-term diet.
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