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A nurse is caring for a client brought to the Emergency Department as one of the first victims of a train accident. The nurse assesses the client, noting a respiratory rate of 38, a weak, rapid pulse, and uncontrolled bleeding. Using NATO guidelines, the nurse assigns which priority tag?

Red tag

Black tag

Green tag

Yellow tag

Answer and Explanation

The Correct Answer is A

Choice A: Red tag

A red tag is assigned to patients who require immediate medical attention and intervention to survive. These patients have life-threatening injuries but have a high chance of survival if treated promptly. In this scenario, the client has a respiratory rate of 38, a weak and rapid pulse, and uncontrolled bleeding. These symptoms indicate severe physiological distress and potential shock, necessitating immediate intervention to prevent death. According to NATO triage guidelines, such critical conditions warrant a red tag to prioritize urgent care1.

Choice B: Black tag

A black tag is used for patients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. This category is also known as “expectant” and is used to allocate resources to those with a higher chance of survival. The client in this scenario, despite having severe symptoms, is not described as being beyond the possibility of survival, thus a black tag would not be appropriate1.

Choice C: Green tag

A green tag is assigned to patients with minor injuries who can wait for medical treatment without immediate risk to life. These patients are often referred to as “walking wounded.” The client’s symptoms of a high respiratory rate, weak and rapid pulse, and uncontrolled bleeding are far too severe to be classified under this category. Assigning a green tag would delay critical care, potentially leading to fatal outcomes1.

Choice D: Yellow tag

A yellow tag is for patients who have serious injuries but whose treatment can be delayed without immediate risk to life. These patients need medical attention but are stable enough to wait for a short period. Given the client’s symptoms, particularly the uncontrolled bleeding and signs of shock, delaying treatment could result in rapid deterioration. Therefore, a yellow tag would not be suitable in this case1.

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A. Recommend the client engage in high-impact, vigorous exercises to improve muscle strength. B. Teach the client stress management techniques such as deep breathing and meditation. C. Advise the client to avoid social interactions to minimize stress. D. Encourage the client to void every hour.

Correct Answer is B

Explanation

Choice A reason:

Recommending high-impact, vigorous exercises is not appropriate for clients with MS. These exercises can increase the risk of injury and exacerbate symptoms. Instead, low-impact exercises such as swimming, yoga, and stretching are more suitable for improving muscle strength and overall fitness without causing undue stress on the body.

Choice B reason:

Teaching the client stress management techniques such as deep breathing and meditation is an important intervention for managing MS. Stress can exacerbate MS symptoms, so learning effective stress management strategies can help the client maintain better control over their condition and improve their quality of life.

Choice C reason:

Advising the client to avoid social interactions to minimize stress is not a healthy recommendation. Social support is crucial for mental and emotional well-being. Instead of avoiding social interactions, the client should be encouraged to engage in supportive and positive social activities that do not cause stress.

Choice D reason:

Encouraging the client to void every hour is not a standard intervention for MS unless the client has specific bladder control issues. Bladder training and scheduled voiding may be recommended for clients with urinary symptoms, but this should be tailored to the individual’s needs and not applied universally.

A. Place the client on a low-protein, low-calorie diet. B. Teach the client to walk more quickly when ambulating. C. Complete passive range-of-motion exercises daily. D. Give the patient extra time to perform activities.

Correct Answer is D

Explanation

Choice A reason:

Placing the client on a low-protein, low-calorie diet is not appropriate for managing bradykinesia in Parkinson’s disease. While dietary adjustments may be necessary for overall health, they do not directly address the motor symptoms of Parkinson’s. In fact, protein intake needs to be managed carefully to avoid interference with medication absorption, but a low-calorie diet is not typically recommended.

Choice B reason:

Teaching the client to walk more quickly when ambulating is not advisable for someone with bradykinesia. Parkinson’s disease often causes difficulty with movement initiation and control, and encouraging faster walking could increase the risk of falls. Instead, strategies to improve gait and balance, such as physical therapy, are more appropriate.

Choice C reason:

Completing passive range-of-motion exercises daily can be beneficial for maintaining joint flexibility and preventing stiffness. However, this action alone does not specifically address bradykinesia, which is characterized by slowness of movement. Active exercises and physical therapy are more effective in managing bradykinesia.

Choice D reason:

Giving the patient extra time to perform activities is crucial for managing bradykinesia. Clients with Parkinson’s disease often need more time to complete tasks due to the slowness of movement. Allowing extra time helps reduce frustration and promotes independence, making it an essential part of care.

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Correct Answer is B

Explanation

Correct Answer is D

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