A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

Choice A reason: Continuing with the triage process is not an immediate intervention that needs to be taken by the triage nurse, as it may expose more people to the chemical hazard and worsen the situation. The triage nurse should stop the triage process and alert the emergency department staff and management about the potential contamination. The triage nurse should also follow the facility's emergency preparedness plan and protocols for dealing with chemical spills.

Choice B reason: Evacuating the emergency department is an immediate intervention that needs to be taken by the triage nurse, as it helps to protect the safety and health of the staff, clients, and visitors. The triage nurse should assist with evacuating everyone from the emergency department to a safe and designated area, away from the source of contamination. The triage nurse should also ensure that everyone is accounted for and that no one re-enters the emergency department until it is cleared by the authorities.

Choice C reason: Placing the client in a private room is not an immediate intervention that needs to be taken by the triage nurse, as it may not prevent the spread of contamination or provide adequate care to the client. The client who have been exposed to a chemical spill should not be moved to another area of the facility, as they may contaminate other people or surfaces along the way. The client should be kept in a separate and isolated area until they are decontaminated and assessed.

Choice D reason: Treating the client after contaminated items are removed is not an immediate intervention that needs to be taken by the triage nurse, as it may delay or compromise the care of the client. The client who has been exposed to a chemical spill should be treated as soon as possible, as some chemicals can cause serious or irreversible damage to the skin, eyes, lungs, or other organs. The triage nurse should provide basic life support measures, such as airway management, oxygen therapy, or bleeding control while wearing appropriate personal protective equipment (PPE). The triage nurse should also remove any contaminated clothing or jewelry from the client and place them in a sealed bag.

Choice E reason: Sending the client and EMS crew to decontamination is an immediate intervention that needs to be taken by the triage nurse, as it helps to remove or neutralize any harmful chemicals from their skin, hair, or clothing. The triage nurse should direct or escort the client and EMS crew to a designated decontamination area or unit, where they will undergo a thorough washing process with water and soap or other solutions. The triage nurse should also monitor their vital signs and symptoms during and after decontamination.

Choice A reason: The integumentary system is a portal of entry for anthrax because the bacteria can enter through cuts or abrasions on the skin. This is called cutaneous anthrax, and it is the most common and least deadly form of anthrax infection.

Choice B reason: The endocrine system is not a portal of entry for anthrax because the bacteria do not affect the glands or hormones of the body. The endocrine system is mainly involved in regulating metabolism, growth, development, and reproduction.

Choice C reason: The central nervous system is a portal of entry for anthrax because the bacteria can spread to the brain and spinal cord from other parts of the body. This is called meningeal anthrax, and it is a rare and fatal complication of anthrax infection.

Choice D reason: The renal system is not a portal of entry for anthrax because the bacteria do not infect the kidneys or urinary tract. The renal system is mainly involved in filtering waste products and excess fluids from the blood.

Choice E reason: The respiratory system is a portal of entry for anthrax because the bacteria can be inhaled into the lungs. This is called inhalation anthrax, and it is the most deadly form of anthrax infection.