A triage nurse finds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?

Choice A Reason

The client reports relief from pain when lying in the prone position. This statement is incorrect. Clients with a herniated lumbar disc typically find relief from pain when lying on their back with their knees bent or in a fetal position. Lying prone can sometimes exacerbate the pain.

Choice B Reason

The client reports that their low-back pain radiates upward toward one scapula. This statement is incorrect. Pain from a herniated lumbar disc usually radiates downward into the buttocks, legs, and sometimes the feet, not upward toward the scapula.

Choice C Reason

The client reports tingling and a burning sensation in one foot. This is the correct finding. A herniated lumbar disc can compress spinal nerves, leading to symptoms such as tingling, numbness, and a burning sensation in the legs and feet.

Choice D Reason

The client reports decreased pain when the affected leg is raised. This statement is incorrect. Raising the affected leg often increases pain due to the stretching of the sciatic nerve, which can be compressed by the herniated disc.

Choice A Reason

Determine the time the last dose of pain medication was administered. While it is important to know when the last dose of pain medication was given, assessing the client’s current pain level is a priority. This helps in understanding the severity and nature of the pain, which guides further interventions.

Choice B Reason

Reposition the client to assist with reduction of pain. Repositioning can help alleviate pain, but it should be done after assessing the pain. Without understanding the pain’s characteristics, repositioning might not address the underlying issue effectively.

Choice C Reason

Ask the client to describe the pain and rate it on a scale of 0 to 10. This is the correct first action. Pain assessment is crucial in determining the appropriate intervention. By asking the client to describe and rate their pain, the nurse can tailor the pain management plan to the client’s specific needs.

Choice D Reason

Check the client’s medical record for type of PRN pain medication. Reviewing the medical record for PRN pain medication is important, but it should follow the initial pain assessment. Knowing the pain’s intensity and characteristics will help in deciding whether PRN medication is needed.