Question

A nurse on the scene following a mass casualty explosion is triaging a client who has a large, open occipital wound and the following findings: r/r 6/min, agonal pattern, cap refill 4.5 secs, nonresponsive to painful stimuli. Which of the following actions should the nurse take?

A) - Turn the client to left semi-fowlers position and begin assessing the next client.

B) - Place a firm pressure dressing to the occiput and open the airway.

C) - Apply a cervical spine color and perform a focused neuro exam

D) - Request that the client be assessed immediately by the next available provider

Answer 1

D) - Request that the client be assessed immediately by the next available provider. The nurse should immediately request assessment by the next available provider due to the severe head injury and vital signs indicating a critical condition. Neurological assessment is crucial to ascertain the extent and location of the central nervous system injury and administer prompt care.

Step-by-step explanation:

The nurse on the scene following a mass casualty explosion is triaging a client with a large, open occipital wound, an agonal breathing pattern at 6 respirations per minute, a capillary refill time of 4.5 seconds, and nonresponsiveness to painful stimuli. The correct action for the nurse to take would be to request that the client be assessed immediately by the next available provider (Option D). Given the severity of the injuries and vital signs that suggest imminent life threat, this patient is likely in a severe neurogenic shock due to cranial trauma affecting neurological function, which can be compounded by a potential basilar fracture of the occipital bone that could lead to life-threatening complications.

Rapid assessment of neurological function is essential in an emergency situation because it helps health care providers determine the extent of the injury and initiate appropriate intervention quickly. This also assists in identifying the exact location of the CNS injury, which is crucial for administering specific and immediate care. In cases of basal fractures, these can be life-threatening due to the potential disruption to the vital structures in the base of the skull, such as blood vessels and nerves, and an increased risk of complications like neurogenic shock.