Nursing Prioritization Delegation Assignment Q 20
A 25-year-old client comes to the outpatient unit with complaints of diarrhea, abdominal pain, shortness of breath, and epistaxis. Which action should the nurse take first?
A. Learn whether the client has had recommended immunizations.
B. Ask the client about any recent travel to Asia or the Middle East.
C. Have the client pinch the anterior nares firmly for 5 minutes.
D. Request an ambulance to take the client quickly to the hospital.
Correct Answer: B. Ask the client about any recent travel to Asia or the Middle East.
Based on the client’s manifestations, avian influenza (“bird flu”) is suspected. Outbreaks of bird flu have occurred in Asia or the Middle East. Airborne and contact precautions should be instituted immediately. Although adapted to birds, and often causing only mild illness, avian influenza viruses can be extremely dangerous with successful transmission to humans with a high percentage of confirmed cases requiring hospitalization and frequently intensive care unit (ICU) care.
Option A: Any patient hospitalized with a suspected or confirmed diagnosis of avian influenza should have an infectious disease consultation to better direct care and minimize complications. While the recommendations presented here are necessary for any patient with suspected avian influenza, an infectious disease consultant may be able to better direct treatment for specific avian influenza strains and manage treatment and patient expectations more appropriately.
Option C: After isolating the client accordingly, management of epistaxis may be done. Treatment for anterior bleeding can be started with direct pressure for at least 10 minutes. Have the patient apply constant direct pressure by pinching the nose over the cartilaginous tip (instead of over the bony areas) for a few minutes to try to control the bleed.
Option D: When an outbreak is identified, it is crucial for public health officials to identify at-risk populations and to inform the public of risk factors and ways to detect infection. Because the presence of deadly diseases in a community can incite fear and panic, announcements should include which populations are at low risk for contracting avian influenza.