A pediatric triage nurse in an outpatient clinic is evaluating phone messages left by care… — NCLEX-RN

A pediatric triage nurse in an outpatient clinic is evaluating phone messages left by caregivers. Which client condition requires the most immediate callback and intervention?

A $4$ -year-old child with a history of asthma whose caregiver states the child is only speaking in single words and prefers to sit uprightAnswer
B
A $6$ -month-old infant with a viral intestinal infection who has had three loose stools today and exhibits a slightly depressed anterior fontanelle
C
A $2$ -year-old child with acute otitis media who is pulling at the right ear, crying incessantly, and has a temperature of $101.8^\circ\text{F}$ ( $38.8^\circ\text{C}$ )
D
A $9$ -month-old infant who cries vigorously and refuses to be comforted by a new babysitter when the parents leave the house

Answer

The

4

-year-old child with a history of asthma who is only speaking in single words and prefers to sit upright requires the most immediate intervention.

The correct answer identifies a client experiencing an acute airway and breathing crisis. Speaking in single words and adopting an upright (tripod) position are classic signs of severe respiratory distress and impending respiratory failure. Using the ABC prioritization framework, this life-threatening condition must be addressed before any other client needs.

Step-by-Step Solution

Evaluate each client's presentation to identify the affected physiological or psychosocial system.

The

4

-year-old has an airway/breathing impairment; the

6

-month-old has a circulatory deficit (dehydration); the

2

-year-old has pain and infection; the

9

-month-old is exhibiting a psychosocial developmental behavior.

Identifying the primary system involved is the first step in applying triage and prioritization frameworks.

Apply the Airway, Breathing, Circulation (ABC) framework and Maslow's Hierarchy of Needs to rank the clients.

The airway and breathing emergency (asthma exacerbation) takes precedence over circulation (dehydration), basic physiological comfort (ear pain), and psychosocial needs (separation anxiety).

Without a patent airway and adequate ventilation, all other physiological systems will rapidly fail, making it the highest acuity concern.

Key Concept

Prioritizing Client Care Using the ABC Framework

Question

Answer

Step-by-Step Solution

Key Concept

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