Multiple clients arrive at the emergency department. Which client should the triage nurse prioritize for the health care provider to see first?

Question

Quizplus · Accepted Answer

Clients with dementia are expected to be alert, with a gradual development of symptoms showing cognitive decline (eg, disorientation, forgetfulness). The sudden onset of a new behavior (eg, restlessness, confusion) may indicate delirium caused by an infection (eg, pneumonia, urinary tract infection) or another serious etiology (eg, hypoglycemia, stroke, hypoxemia) and is considered a priority (Option B). (Option A) The client at 24 weeks gestation with a productive cough and no signs of labor may have an upper respiratory infection but is currently stable and not the priority. Pregnant clients and children are not automatic priorities. (Option C) The client who had a seizure earlier is now stable. The nurse can maintain a safe environment (ie, in the event of another seizure) until the client is seen, but the client with dementia and behavior changes is the priority. (Option D) The client with a potential fracture and pain has normal circulation and sensation. Although further evaluation and treatment (eg, x-rays, analgesics, ice, elevation) are needed, this client is not the priority. Educational objective: Clients with dementia are expected to be in an alert but disoriented state with gradual development of symptoms. The sudden onset of a new behavior (eg, restlessness, confusion) may indicate delirium caused by an infection or another serious etiology (eg, hypoglycemia, stroke, hypoxemia) and is considered a priority.

Multiple Clients Arrive at the Emergency Department