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 A
Explanation
Answer and explanation
The correct answer is Choice A.
Choice A rationale
Showering with non-perfumed soaps immediately after practice is a good practice for a teenager with a history of recurring atopic dermatitis (eczema) who wants to play high school sports. Heat and humidity can cause perspiration, which intensifies itching with atopic dermatitis (eczema), so the client should be encouraged to shower, using non-perfumed soaps, as soon as possible after physical activity to remove perspiration.
Choice B rationale
Informing the parents of problems associated with perspiration for those with eczema is also important. However, this does not directly address the teenager’s desire to play sports. It’s more of a secondary action that supports the primary action of managing the condition.
Choice C rationale
Informing the athletic coach of the teenager’s skin condition and its manifestations could be helpful in ensuring that the coach understands the teenager’s needs and can support them appropriately. However, this is not the most direct action that the nurse can take to help the teenager manage their condition while playing sports.
Choice D rationale
Encouraging the teenager to join the swim team instead of an outdoor sport could potentially reduce exposure to triggers for eczema flares, such as sweat and heat. However, chlorine in swimming pools can also be a trigger for some people with eczema. Therefore, this option might not be the best for everyone and should be considered on an individual basis.
Correct Answer is D
Explanation
Answer and explanation
The correct answer is Choice D.
Choice A rationale
While suggesting that the patient get a walker might help with mobility, it does not directly address the safety concerns in the home environment.
Choice B rationale
A medical alert device could be beneficial in case of emergencies, but it does not prevent the risk of falls or accidents in the home.
Choice C rationale
Ensuring the patient’s privacy is important, but it does not address the immediate safety concerns observed by the nurse.
Choice D rationale
Identifying potential safety hazards in the home is the most immediate and effective action the nurse can take. By doing this, the nurse can work with the patient and their family to make necessary changes to improve safety and prevent falls.
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