ENPC 6th Ed Chap 4 Prioritization

Question 1

Can PAT only be used for triage?

Answer 1

No can be used at any time (49 CP)

Question 2

TICLS mnemonic

Answer 2

Tone, Interactiveness, Consolibility, Look/Gaze, Speech/Cry (49)

Question 3

SAMPLE mnemonic

Answer 3

Signs/symptoms, Allergies, Medications, Past medical, Last meal, Events leading to illness/injury (60 B)

Question 4

How should the nurse respond to a caregiver describing a child as being “fussy”?

Answer 4

Considered a red flag for serious illness or injury (61)

Question 5

At what rate may children be under-triaged?

Answer 5

up to 33% (47)

Question 6

What three components area assessed during the PAT?

Answer 6

Appearance, Work of breathing, Circulation TO THE SKIN (48)

Question 7

Under the “Appearance” component of the PAT, what is assessed?

Answer 7

TICLS (48)

Question 8

Under the “Work of Breathing” component of the PAT, what is assessed?

Answer 8

1. Abnormal sounds (stridor, wheeze,grunt) SPRFA
2. Abnormal position (tripod)
3. Retractions
4. Flaring
5. Apnea/gasping (48)

Question 9

Under the “Circulation to Skin” component of the PAT, what is assessed?

Answer 9

Pallor, mottling, cyanosis (48)

Question 10

After using the PAT, how are patient ranked?

Answer 10

sick, sicker, sickest (49)

Question 11

What are the criteria for “sick, sicker, sickest”? under the PAT assessment?

Answer 11

sick–all patient
sicker –one abnormal PAT assessment
sickest – 2 or more abnormal PAT assessments (50)

Question 12

If a triaged patients condition changes during the ER visit, what happens to their triage acuity?

Answer 12

“Acuity can change…this does not necessarily mean the triage acuity level changes. (57)

Question 13

How should the nurse approach any ped with AMS?

Answer 13

Should be considered a decrease in cerebral perfusion or hypoglycemia until proven otherwise. (58)

Question 14

What percent of childrens crying is due to organic causes?

Answer 14

5% (61)

Question 15

What temperature at any age is concerning?

Answer 15

> 102.2 (62)

Question 16

What temperature is concerning in a patient less than 90 days old?

Answer 16

> 100.4 (62)

Question 17

What low temperature is concerning at at any age?

Answer 17

< 95 (62)

Question 18

What low temperature is concerning for an infant or neonate?

Answer 18

< 97 may indicate early sepsis (62)

Question 19

Can you assess a rash during the PAT?

Answer 19

Yes, (62)

Question 20

When assessing circulation, what capillary refill time is concerning?

Answer 20

> 2 seconds to fill (63)