A category 4 hurricane has disrupted a rural local health care system, creating a significant increase in emergency department admissions. Which client would the nurse assess first?

Question

Quizplus · Accepted Answer

The child with status asthmaticus is at risk for rapid deterioration of respiratory status and respiratory failure. The clinical finding of decreased oxygen saturation (normal reference is ≥95%) indicates mild-to-moderate status asthmaticus. This client needs to be treated immediately. (Option A) This client needs assessment and monitoring of neurological functioning following head trauma. The client is currently stable and has the least priority at this time. Development of altered mental status, spinal pain, nausea, vomiting, or loss of consciousness would shift the status to a higher priority. (Option B) The clinical findings of fatigue, abdominal pain, and blood glucose level of 690 mg/dL (38.3 mmol/L) indicate developing diabetic ketoacidosis. This client is at risk of life-threatening hemodynamic instability and needs immediate treatment. However, the client can be seen after the child with status asthmaticus and impending respiratory deterioration. (Severe respiratory instability takes precedence over hemodynamic instability.) (Option D) This client's history is indicative of dehydration. She needs restoration of normal fluid balance, but she is not at risk of impending severe respiratory or hemodynamic instability, as are clients 3 and 2. Educational objective: Children age <10 should automatically be upgraded to 1 level higher than the triaged urgency of their medical issues. The combination of status asthmaticus and an oxygen saturation ≤92% qualifies for the highest priority level of triage at any age.

A Category 4 Hurricane Has Disrupted a Rural Local Health