Four clients come to the emergency department simultaneously. Which client should the nurse see first for definitive care?

Question

Quizplus · Accepted Answer

In this scenario, a client with a drug overdose (OD) is the highest priority as the actual amount taken and its effects are unknown. In addition, clients who deliberately OD often consume other substances (eg, alcohol) that can potentiate the effect of the drug. OD is especially concerning for a tricyclic antidepressant (TCA) due to the effect this can have on the cardiovascular and central nervous systems (eg, dysrhythmias, seizures). TCA use for depression is an uncommon second-line treatment, but the drug class is used for neuropathic pain and sometimes bed-wetting (enuresis). A client with head trauma (a vascular area of the body) who is currently on an anticoagulant could have potential intracranial bleeding and should be treated next. The 6-month-old client is exhibiting classic signs of otitis media (eg, fever, ear pulling/rubbing). This infection of the middle ear is a common childhood illness, often in conjunction with an upper respiratory infection. The child should be treated third and will need antibiotics, but this is nonurgent. Antipyretics can be given for comfort by protocol or direct order from the health care provider while the child is still in the triage/waiting area. The 10-day old client's mark is a salmon-colored patch (nevus simplex or angel kiss); this is a developmental vascular abnormality that will disappear within 1 year. It is at the nape of the neck but can also be seen on the eyelid, upper lip, or between the eyes. The mother needs reassurance and teaching. Educational objective: A drug OD is a priority in triage due to its potential lethal and unpredictable effects. Head trauma in a client on anticoagulation is a concern related to potential intracranial bleeding. The classic signs of otitis media are fever and ear pulling/rubbing. The stork bite is a normal finding.

Four Clients Come to the Emergency Department Simultaneously