Mr. CT is a 73-year-old man who

Mr. CT is a 73-year-old man who was bought to the emergency room (ER) by his daughters for altered mental status. Mr. CT oldest daughter tells the triage nurse that the patient went fish last week and got a fishhook stuck in his finger. However, he was able to remove the fishhook without going to his doctor or the emergency room (ER). This morning the daughter noticed that Mr. CT kept going around the house looking for his wife to cook him some breakfast. However, his wife has been dead for five years. She stated this was very unusual for the client, and the daughter called her sister over and they decided to bring Mr. CT into the emergency room. The triage nurse assesses vital signs and does a quick neurologic assessment. The assessment findings are listed below. Vital Signs Neurologic Assessment Findings Temp: 97 Orientation: 2/3 (oriented to person and place) HR:105 PERRLA Present: pupils 3mm Blood Pressure: 100/65 HEENT: Normal gaze, no facial palsy, equal smile, no tongue deviation, productive cough Oxygen Sat: 94% (on room air) Motor: No drift, follows commands, equal strength X4 Sensory: No sensory loss The triage nurse gives report to the ED nurses. Use an X to indicate whether the nursing actions below are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (make no difference or are not necessary) for the client’s care at this time. Nursing Action Indicated Contraindicated Non-Essential Administer a D5W 1000-ml bolus Insert an IV Start broad spectrum Antibiotic Draw comprehensive metabolic profile (CMP) Place on oxygen via nasal cannula SCIENCE HEALTH SCIENCE NURSING NURS 132

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