Safe, Effective Care Environment
16. Four clients walked into an ambulatory clinic at the same time. Which client should a nurse assess first?
Safe, Effective Care Environment
16. Four clients walked into an ambulatory clinic at the same time. Which client should a nurse assess first?
. A 45-year-old client with a swollen, bruised ankle, who is limping.
. A 30-year-old client with a temperature of 102°F, vomiting, and diarrhea.
. A 40-year-old client with a sore throat, temperature 101°F, swollen lymph glands.
. A 35-year-old client complaining of a severe headache, vomiting, and stiff neck.
Test-Taking Tip
Rule out the conditions that are not life threatening in a young adult or middle-aged adult.
Content Area: Adult Health, Triage; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
Safe, Effective Care Environment
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Answer 1 is incorrect because the signs are consistent with a soft tissue injury, which is not immediately life threatening. Answer 2 is incorrect because the signs and symptoms are not imminently life threatening. The risk of dehydration would be a greater concern in a very young child or an older adult. Answer 3 is incorrect because the signs and symptoms are not imminently life threatening. A throat culture would be indicated to determine if the cause is viral or bacterial. Answer 4 is correct because the classic signs and symptoms of bacterial meningitis in an adult are severe headache and neck stiffness (nuchal rigidity). This is a serious condition because of the proximity to the brain and spinal cord and the possibility of sepsis.