Reference no: EM133787477

Question

Screen 1 of 6 The nurse in the Emergency Department ( ED) is triaging clients when an adult client is brought in by a neighbor The nurse speaks with the client's neighbor while obtaining vital signs Which finding is concerning to the nurse ? ( Select all that apply .) Triage Notes 1. BP 178/88 . 2. Client's skin is pale and diaphoretic . 3. RR 16 . 1345 : Client brought into the ED by a neighbor . The neighbor reports that when the client did not answer the door , the neighbor looked through the window and saw the client lying on the floor against the couch . The neighbor does not know any medical history but is able to provide the first and last name of the client . The client is currently slumped over in a wheelchair , with pale and diaphoretic skin . Moans in response to painful stimuli. 4. Neighbor does not know any medical history . Vital Signs 5. HR 124 . Results 1345 6. Client moans in response to painful stimuli . BP 178/88 7. Temperature 98.1 1 deg * F(36.7 deg * C) HR 124 8. Sp*O_{2} 94.