The emergency department triage nurse is assessing 4 pediatric clients. Which client is a priority for further diagnostic workup and definitive care?

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A ventriculoperitoneal shunt is used to treat hydrocephalus and is usually placed at age 3-4 months. Blockage and infection are complications of shunt placement. Blockage results in signs of increased intracranial pressure (ICP). The normal pulse range for a 1-year-old is 100-160/min. A pulse of 78/min is considered bradycardia, a part of Cushing's triad (bradycardia, slowed respiration, widened pulse pressure). (Option B) Meningocele is a saclike protrusion through a bony defect that contains meninges and cerebrospinal fluid; it is corrected with surgery. In some children, residual bowel and bladder incontinence can result despite surgery. If bowel and bladder control is obtained but incontinence reoccurs, the child should be evaluated for infection (a common complication). Although the child with ear pain (eg, otitis media) may need antibiotics, this is not urgent and the client with neurological signs is the priority. (Option C) Muscular dystrophy is an inherited condition of muscle fiber degeneration and muscle wasting. Respiratory and cardiac problems are the leading causes of mortality. These clients should take precautions to prevent respiratory infections (eg, pneumococcal and influenza vaccination, avoiding contact with infected individuals). This client is the second priority after the client with increased ICP and possible brain herniation. (Option D) Cerebral palsy is a permanent disorder of movement, with abnormal muscle tone, lack of physical coordination, spasticity, and compromised posture development causing activity limitation. Clonus is a series of involuntary, rhythmic, muscular contractions and relaxations. Spasticity/clonus is an expected finding in a client with cerebral palsy. Foot injury in this client is not a priority. Educational objective: A ventriculoperitoneal shunt is used to treat hydrocephalus. Complications include blockage (with signs of increased intracranial pressure [ICP]) and infection. The normal pulse range for a 1-year-old is 100-160/min; bradycardia can be a sign of increased ICP.

The Emergency Department Triage Nurse Is Assessing 4 Pediatric Clients