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Difficulty: Very hardEstablishing Priorities

A registered nurse on a pediatric high-acuity unit is receiving the morning hand-off report for four assigned clients. Based on the provided clinical data, which client should the nurse assess first?

  1. A
    A 2-year-old client with respiratory syncytial virus (RSV) bronchiolitis who has a respiratory rate of 44 breaths/minute, mild intercostal retractions, and an oxygen saturation of 92% on room air
  2. B
    A 4-year-old client with Kawasaki disease receiving an intravenous immunoglobulin (IVIG) infusion who has a temperature of 100.8°F (38.2°C) and exhibits extreme irritability
  3. A 6-year-old client with acute poststreptococcal glomerulonephritis who has a blood pressure of 145/95 mm Hg and reports a sudden, severe headacheAnswer
  4. D
    A 10-year-old client with a vaso-occlusive sickle cell crisis receiving intravenous hydration who reports deep bone pain rated as 8 on a 0 to 10 scale

Answer

The 6-year-old client with acute poststreptococcal glomerulonephritis who has a blood pressure of 145/95 mm Hg and reports a sudden, severe headache.
The correct answer identifies a severe, unexpected complication. Acute poststreptococcal glomerulonephritis causes fluid retention and subsequent hypertension. For a 6-year-old, a blood pressure of 145/95 mm Hg is dangerously high (normal is approximately 95-105/60-70 mm Hg). The addition of a sudden, severe headache indicates hypertensive encephalopathy, a medical emergency that can rapidly lead to cerebral edema, seizures, or a cerebrovascular accident (stroke) if intravenous antihypertensives are not administered immediately.

Step-by-Step Solution

1
Analyze the clinical data for each pediatric client to establish expected baseline findings versus unexpected complications.
Three clients present with expected manifestations of their underlying illness, while one presents with a lethal complication.
Prioritization requires distinguishing between loud, expected symptoms and subtle, life-threatening acute changes.
2
Evaluate the respiratory status of the toddler with RSV.
Tachypnea (44 breaths/min), mild retractions, and a 92% oxygen saturation are determined to be stable, expected baselines for this condition.
Airway and breathing are priorities, but stable, expected respiratory distress does not override an active, unexpected emergency.
3
Assess the vital signs and neurological status of the 6-year-old with glomerulonephritis.
A blood pressure of 145/95 mm Hg is identified as severe hypertension for a 6-year-old. The sudden headache indicates neurological compromise.
Acute poststreptococcal glomerulonephritis can lead to sudden hypertensive crisis, which can rapidly progress to hypertensive encephalopathy.
4
Prioritize the client with the most immediate threat to life.
The client with glomerulonephritis is selected as the highest priority.
Impending seizures or stroke from hypertensive encephalopathy demands immediate medical intervention.

Key Concept

In pediatric triage, nurses must synthesize age-appropriate vital sign norms with disease pathology to prioritize clients experiencing unexpected, life-threatening complications (e.g., hypertensive encephalopathy) over those with loud but expected manifestations of their disease process (e.g., mild retractions in RSV, irritability in Kawasaki disease).
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Establishing Priorities

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