The nurse is triaging clients in the emergency department. Which client needs to be seen first?

Question

Quizplus · Accepted Answer

Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may be auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. This client may need emergency surgery to repair the aneurysm. (Option A) Fever, suprapubic pain, and dysuria in a young female client indicate urinary tract infection, a much lower priority than AAA. (Option B) Diffuse pain and a rigid abdomen indicate peritonitis (eg, from ruptured appendicitis or perforated bowel). Peritonitis is also an emergency but not immediately life-threatening like AAA rupture. This client should be seen next after the client with AAA. (Option D) Fever and left lower quadrant pain in an elderly client are usually due to acute diverticulitis. The client needs bowel rest, antibiotics, and IV fluids. This is a lower priority than AAA and peritonitis. Educational objective: Clients with an impending aortic aneurysm rupture present with abdominal/back pain, and a pulsatile abdominal mass. They may also have a bruit. Rupture of an abdominal aneurysm can lead to exsanguination and death in minutes.

The Nurse Is Triaging Clients in the Emergency Department