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    RN Medical Surgical HESI Proctored Exam

    Exhibits The triage nurse does a rapid assessment of the client. Which data indicates the client is in need of immediate health interventions?

    Explanation & Rationale

    a) The client's age: The client is 70 years old, which puts her at a higher risk of having a stroke or other cardiovascular problems. Stroke is a medical emergency that requires prompt treatment to prevent brain damage and disability. b) The client's facial droop: The client has a noticeable facial droop, which is a sign of facial nerve weakness or paralysis. This can be caused by a stroke, Bell's palsy, or other neurological conditions. Facial droop can affect the client's ability to speak, eat, and express emotions. c) The client's garbled speech: The client has garbled speech, which means she has difficulty producing or understanding words. This can be caused by a stroke, brain injury, or other disorders that affect the language areas of the brain. Garbled speech can impair the client's communication and cognition. d) The client's alcohol consumption: The client had a few drinks at a seafood restaurant, which may have interacted with her medications or medical conditions. Alcohol can increase the risk of bleeding, lower blood pressure, and worsen dehydration. Alcohol can also impair the client's judgment and coordination. e) The client's seafood intake: The client ate seafood at a restaurant, which may have triggered an allergic reaction or food poisoning. Seafood allergies can cause symptoms such as hives, swelling, breathing difficulties, and anaphylaxis. Food poisoning can cause symptoms such as nausea, vomiting, diarrhea, and dehydration.

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