The ED nurse is working in triage on a summer weekend. The following clients present at the same time. Which client does the nurse anticipate being seen first ?
an infant with fever, a shrill cry, diarrhea, and nuchal rigidity
a 38-year-old jogger who twisted her ankle, has a good pedal pulse, and has no deformity
a 46-year-old client who was working outside and has tachypnea, diaphoresis, and fatigue
an ambulatory child who fell off a bicycle and hit his head on grass while wearing a helmet
Number 2 is correct.
Rationale: Fever, a shrill cry, diarrhea, and nuchal rigidity indicate meningitis, which is a medical emergency. The infant must be placed on respiratory isolation immediately, monitored for seizures, and prepared for a lumbar puncture. Those in close contact with the infant may need prophylactic treatment as well. The client with abdominal pain and nausea is stable at this moment and can be seen later. The jogger is not the top priority because she has a good pedal pulse and no deformity in the ankle, which indicates that she is stable. The client who was working outside and presents with tachypnea, diaphoresis, and fatigue is at risk for heat syncope and should rest in a cool area and be taught to limit exposure in extreme heat, take frequent breaks, and drink plenty of water. This client is also stable. The child who fell off a bicycle onto grass while wearing a helmet is ambulatory, wore protection, and landed on a soft surface. Although he should still have an assessment to check for head injuries, he is not currently in a life-threatening situation like the infant.
