You are assigned to reassess an eight-year-old boy in the emergency department, who was triaged (tagged) with a green tag on the scene. You were told that the boy was responsive to commands on the scene, yet has become unresponsive following transport to the hospital, in your evaluation of the eight-year-old boy, you should:
Change his triage (color) tag to needing immediate care-red or yellow
Agree with the on scene decision and keep the triage (color) tag as is
Change the level to green
Change his triage (color) tag to black
The Correct Answer is A
Rationale:
A. Triage in a mass casualty incident is a dynamic and continuous process. A patient’s status may change from the time of the scene assessment to arrival at the hospital. This eight-year-old boy was initially tagged green, indicating minor injuries or stable condition. However, upon reassessment, he is now unresponsive, which is a critical change that signifies a potentially life-threatening deterioration. According to triage protocols such as START (Simple Triage and Rapid Treatment) or pediatric modifications like JumpSTART, an unresponsive child requires immediate medical attention. The triage color should be upgraded to red (for immediate intervention if there are life-threatening injuries with a chance of survival) or yellow (for urgent care if life-threatening injuries are present but not immediately critical), ensuring he receives prompt treatment. Re-triaging prevents delays in interventions that could be lifesaving.
B. Triage decisions are based on the patient’s current clinical condition, not the initial assessment. Sticking with the green tag despite the patient now being unresponsive would delay critical interventions, potentially worsening outcomes and increasing mortality risk.
C. Green tags are reserved for patients with minor injuries who can safely wait for treatment. An unresponsive child is not minor, and assigning green in this situation would be unsafe and inappropriate.
D. Black is used for deceased patients or those with injuries so severe that survival is unlikely even with immediate treatment. Since the patient is unresponsive but still has a chance of survival with rapid intervention, black is not appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Spinal shock refers to a temporary loss of all reflexes, sensation, and motor function below the level of a spinal cord injury. It affects neurologic function but does not inherently cause hypotension or bradycardia. While the patient has quadriplegia and may be in spinal shock, this does not explain the vital sign abnormalities observed.
B. Hemorrhagic shock occurs due to blood loss, leading to hypotension and tachycardia as a compensatory response. In this patient, the pulse is bradycardic (52 bpm) rather than tachycardic, which is inconsistent with hemorrhagic shock physiology. Although he has a gunshot wound, his vital signs are not typical of hypovolemic shock.
C. Neurogenic shock occurs after a spinal cord injury, especially above T6, resulting in loss of sympathetic tone. This leads to hypotension (BP 90/50) due to vasodilation and bradycardia (pulse 52) due to unopposed parasympathetic activity. The patient’s C3-C4 quadriplegia and vital signs are classic for neurogenic shock.
D. While the patient may also experience spinal shock neurologically, the hemodynamic findings (bradycardia and hypotension) are specific to neurogenic shock. Hemorrhagic shock is unlikely based on the bradycardia, so “all of the above” is incorrect.
Correct Answer is ["A","D"]
Explanation
Rationale:
A. The patient has a localized injury without signs of hemodynamic instability, internal bleeding, or organ compromise. While the injury is significant enough to require treatment, it is not immediately life-threatening, fitting the yellow tag (delayed care) category.
B. Ocular injuries, especially bilateral or penetrating injuries, are potentially vision-threatening and may require urgent surgical evaluation. Such patients are triaged red (immediate).
C. Neurologic deficits after trauma suggest spinal cord involvement, which is a high-priority, potentially life- or function-threatening injury. These patients are tagged red (immediate).
D. Burns that cover less than a critical total body surface area without airway involvement or signs of shock are serious but not immediately life-threatening, fitting yellow tag (delayed care). Patients can safely wait for definitive treatment while higher-priority cases are stabilized.
E. Altered level of consciousness is a critical sign of intracranial injury and possibly rising intracranial pressure. This requires immediate intervention, and the patient would be tagged red.
F. Absent distal pulses indicate vascular compromise, putting the patient at risk for limb loss or systemic complications. This is life- or limb-threatening and requires red (immediate) care.
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