A school nurse is helping emergency medical services (EMS) triage students after a bus accident occurred in the school parking lot. A 10-year-old client is awake, alert, and ambulatory but reports a headache and neck pain. Using START triage, what acuity level would be assigned to this client?

Choice A reason: The acuity level of the clients is a critical factor to consider when planning staff assignments. Clients with higher acuity levels require more intensive care and monitoring, necessitating a greater allocation of resources and experienced staff. By considering client acuity, the charge nurse can ensure that the most critical patients receive the appropriate level of care and attention, while also balancing the workload among the nursing staff.

Choice B reason: The clustering of the rooms on the unit can significantly impact the efficiency of care delivery. By grouping clients in close proximity, the nurse can minimize the time and effort spent moving between rooms, thus enhancing the ability to respond quickly to client needs. This consideration helps to optimize workflow and improve overall patient care by reducing potential delays.

Choice C reason: Considering both client needs and the staff's needs and abilities ensures that the right personnel are assigned to the appropriate tasks. Matching staff competencies with client requirements maximizes the effectiveness of care delivery. Additionally, taking into account staff preferences and skills can improve job satisfaction and performance, ultimately benefiting the clients.

Choice D reason: The number of anticipated client discharges is an important logistical factor that can affect the day's workflow. Planning for discharges allows the charge nurse to allocate resources for discharge planning, patient education, and follow-up care. It also helps in managing bed availability and preparing for incoming admissions, ensuring a smooth transition for both clients and staff.

Choice E reason: Specific requests from the staff can include preferences for certain shifts, working with particular patients, or avoiding specific tasks. While it may not always be possible to accommodate all requests, considering them when feasible can improve staff morale and cooperation. Addressing staff preferences helps to create a positive work environment, leading to better teamwork and patient outcomes.

Choice A reason: While the client with a subarachnoid hemorrhage needs close monitoring, the administration of nimodipine is essential but not immediately life-threatening compared to the post-tPA monitoring requirements.

Choice B reason: This client received tissue plasminogen activator (tPA) 8 hours ago, which is critical for treating ischemic stroke. They are at a high risk of complications such as bleeding and must be monitored closely for any signs of adverse effects, making them the priority.

Choice C reason: The client with chronic atrial fibrillation due for warfarin can be attended to after addressing more urgent needs. Chronic atrial fibrillation management is important, but it is less urgent than post-tPA care.

Choice D reason: The client who experienced a transient ischemic attack and is due for aspirin is stable compared to the client who recently received tPA. While aspirin is important for preventing further strokes, it does not require the same level of immediate monitoring as the post-tPA client.