The nurse in the emergency department (ED) is made aware that an unaccompanied 15-year-old client has arrived in the waiting room with altered mental status reports of a severe headache.
The nurse should initially
The nurse in the emergency department (ED) is made aware that an unaccompanied 15-year-old client has arrived in the waiting room with altered mental status reports of a severe headache.
The nurse should initially
A. contact the police so the client's parents can be located.
[3%]
B. obtain the client's vital signs and perform an assessment.
[95%]
C. keep the client in the waiting room until a family member can be reached.
[1%]
D. research the client's demographic information from previous medical records.
[1%]
Statistics
Subject/Lesson
Subject
Leadership & Management
Lesson
Ethical/Legal
Client Need
Test Plan
Management of Care
Related Topic
Informed Consent
Item Type
Item Type
Application
Explanation
Choice B is correct. The priority action when an unaccompanied minor presents to the ED with altered mental status and severe headache is to initiate immediate assessment to determine clinical stability. Altered mental status may indicate a life-threatening condition such as meningitis, intracranial hemorrhage, or severe head trauma. Unaccompanied minors may receive emergency care if their condition constitutes an emergency.
Choice A is incorrect. Locating guardians is important for consent in a minor, but medical stabilization always prioritizes administrative or legal actions. Consent for emergency care in life-threatening situations is implied.
Choice C is incorrect. Keeping the client in the waiting room until a family member can be reached is unsafe and constitutes a delay in care. Given the client's mental status and severe headache, there is a significant risk of rapid decline, including airway compromise, seizure activity, or neurological collapse. The nurse must immediately bring the client into an appropriate care area for evaluation and stabilization.
Choice D is incorrect. Reviewing previous medical records to help locate a client's or guardian may be helpful, but this would delay assessing and stabilizing the client, especially in the context of altered mental status and severe headache. The client's needs are the priority.
Related Videos
2 Key Topics
Informed Consent
15.1 Documentation, Consent & Information Systems
Additional Info
✓ All clients presenting to an emergency center receive screening for an emergency medical condition and required stabilization for such a condition.
✓ Emergency medical treatment may be administered without consent if an attempt to secure such consent would delay treatment and risk the patient's life or health.
✓ When emergency care is required, the client should be treated and the parents or legal guardians notified as soon as possible.
