A nurse in an urgent care center triages multiple clients. Which client should the nurse assess first?

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11ecbb05_ca77_9dad_b433_15e1e7c6976f_MD0009_00 Peritonsillar, or retropharyngeal, abscess is a serious complication that can result from tonsillitis or pharyngitis. The presenting features of peritonsillar abscess, in addition to fever, include a "hot potato" (muffled) voice, trismus (inability to open the mouth), pooling of saliva (drooling), and deviation of the uvula to one side. The abscess can progress to life-threatening airway obstruction (eg, dysphagia, stridor, restlessness). The nurse should immediately assess the client with symptoms of peritonsillar abscess and monitor for signs of airway obstruction (Option C). (Option A) A client with epistaxis (ie, nosebleed) that does not resolve with external pressure will require further hemostatic interventions, such as cauterization or nasal packing (eg, gauze, nasal tampon, balloon catheter). This client should be assessed after the client with signs of impending airway obstruction. (Option B) Symptoms of acute sinusitis include severe facial pain, nasal congestion with purulent nasal drainage, and fever. In most cases, the etiology is viral but can be complicated by secondary bacterial infection. This client likely requires antibiotics and supportive care but is not the priority. (Option D) Acute otitis media (ie, infection of the middle ear) may develop secondary to rhinitis (eg, common cold, seasonal allergies) due to inflammation of the Eustachian tube. This client with otitis media will likely require antibiotics and pain management but is not the priority. Educational objective: Peritonsillar abscess is an emergent complication of tonsillitis that can lead to life-threatening airway obstruction. Symptoms of peritonsillar abscess include fever, trismus (inability to open the mouth), drooling, muffled voice, and deviation of uvula to one side.

A Nurse in an Urgent Care Center Triages Multiple Clients