A nurse is triaging a client following a community disaster.

Exhibits

The nurse should identify the client with a Select... –and Select...

A. Report of back pain associated with twisting at the waist. Back pain is a common musculoskeletal issue among agricultural workers due to repetitive movements and heavy lifting. While it requires intervention, it is not immediately life-threatening and does not take priority over acute symptoms that may indicate poisoning or a severe reaction.

B. Absence of a dental health provider. Lack of dental care can contribute to long-term health complications, but it does not pose an immediate risk requiring urgent intervention. Addressing acute medical conditions takes precedence over routine preventive care.

C. Lives in a home with 25 other agricultural workers. Overcrowded living conditions can increase the risk of communicable diseases and poor hygiene-related health issues. However, it is a social determinant of health rather than an urgent clinical concern that requires immediate action.

D. Report of muscle twitching and skin rash. Muscle twitching and skin rash can indicate pesticide poisoning, a common occupational hazard for agricultural workers. Pesticide exposure can lead to serious neurological and systemic effects, making this the priority for immediate assessment and intervention.

A. Suggest that family members discuss the importance of the surgery with the client: While family support can be valuable, the decision ultimately lies with the client. It is essential for the client to feel empowered in their choices without feeling pressured by family members.

B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure: The most appropriate action is to inform the surgeon of the client's decision to withdraw consent. It is the client's right to change their mind about the procedure at any time before it occurs, and the healthcare team must respect and facilitate that decision.

C. Document the risks of refusing the procedure in the client's medical record: While documenting the client's decision is important, focusing solely on the risks of refusal may not be appropriate at this time. The primary concern should be to ensure that the client's wishes are communicated to the healthcare provider.

D. Discuss the benefits of the procedure with the client: Emphasizing the benefits of the procedure may unintentionally pressure the client. It is more important to respect the client's autonomy and decision-making, ensuring they are comfortable with their choice without feeling coerced into changing their mind.