Nursing Prioritization Delegation Assignment Q 68
A high school student comes in the triage area alert and ambulatory, and his uniform is soaked with blood. He and his classmates are sounding, “We were running around outside the school and he got hit in the abdomen with a stick!” Which statement should be a priority?
A. "The stick was absolutely filthy and muddy."
B. "He has a family history of diabetes, so he requires attention right now."
C. "He pulled the stick out because it was too painful for him."
D. "There was plenty of blood so we used three gauzes."
Correct Answer: C. “He pulled the stick out because it was too painful for him.”
An impaled object may be giving a tamponade effect, and removal can result in abrupt hemodynamic decompensation. Surgery is often required; impaled objects are secured in place so that they do not move and they should only be removed in an operating room.
Option A: Penetrating trauma often causes damage to internal organs resulting in shock and infection. The severity depends on the body organs involved, the characteristics of the object, and the amount of energy transmitted.
Option B: Information such as the dirt on the stick or history of diabetes, is significant in the overall treatment plan but can be addressed next. The indications for surgical intervention include a patient with hemodynamic instability, development of peritoneal findings such as involuntary guarding, point tenderness or rebound tenderness, and diffuse abdominal pain that does not resolve.
Option D: Additional history including a more precise extent of blood loss, depth of penetration, and medical history should be collected. If the pancreas is injured, further injury occurs from autodigestion. Injuries of the liver often present in shock because the liver tissue has a large blood supply.