A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?

Choice A: WBC Count

Reason: The white blood cell (WBC) count is not directly related to fall risk. WBC count is an indicator of the immune system’s response to infection or inflammation. In this case, the patient’s WBC count is within the normal range (5,000 to 10,000/mm³) on both days. Therefore, it does not contribute to an increased risk of falls.

Choice B: Parkinson’s disease

Reason: Parkinson’s disease significantly increases the risk of falls due to several factors. Patients with Parkinson’s often experience postural instability, which is the inability to maintain balance when standing or walking. This condition is a cardinal feature of Parkinson’s disease and can lead to frequent falls. Additionally, Parkinson’s patients may experience freezing of gait, where they suddenly cannot move their feet forward despite the intention to walk. This can cause them to fall. Other gait abnormalities, such as festinating gait (short, rapid steps) and dyskinesias (involuntary movements), also contribute to the increased fall risk.

Choice C: Potassium level on day 2

Reason: The patient’s potassium level on day 2 is 3.0 mEq/L, which is below the normal range of 3.5 to 5 mEq/L. Low potassium levels (hypokalemia) can lead to muscle weakness, cramps, and fatigue. These symptoms can impair the patient’s ability to maintain balance and increase the risk of falls. Hypokalemia can also cause abnormal heart rhythms, which can further contribute to the risk of falls.

Choice D: Furosemide

Reason: Furosemide is a diuretic medication used to treat conditions such as heart failure by reducing fluid buildup in the body. However, it can also cause orthostatic hypotension, a condition where blood pressure drops significantly when standing up. This can lead to dizziness, lightheadedness, and an increased risk of falls. Additionally, furosemide can cause electrolyte imbalances, such as low potassium levels, which can further contribute to fall risk.

Choice E: Low blood pressure

Reason: The patient’s blood pressure readings indicate orthostatic hypotension, with a significant drop from 128/56 mm Hg while sitting to 92/40 mm Hg while standing. Orthostatic hypotension is a common condition in patients with Parkinson’s disease and heart failure. It can cause dizziness, lightheadedness, and fainting when changing positions, increasing the risk of falls. The patient’s low blood pressure when standing is a clear indicator of increased fall risk.

1. a) Inspect the abdomen for skin integrity: The first step in an abdominal assessment is inspection. The nurse should visually examine the abdomen for any abnormalities such as skin changes, scars, distention, or masses.
2. b) Ask the client about having a history of abdominal pain: Gathering a history of abdominal pain is crucial as it provides context for the physical findings. This step helps identify any underlying conditions that may influence the assessment.
3. c) Auscultate the abdomen for bowel sounds: Auscultation should be performed before palpation and percussion to avoid altering the bowel sounds. The nurse listens for the presence, frequency, and character of bowel sounds in all four quadrants.
4. d) Percuss the abdomen in each of the four quadrants: Percussion helps to assess the presence of fluid, air, or masses in the abdomen. The nurse taps on the abdomen to listen for sounds that indicate the underlying structures.
5. e) Palpate the abdomen gently for tenderness: Palpation is the final step and involves gently pressing on the abdomen to check for tenderness, masses, or organ enlargement. This step should be done last to avoid causing discomfort or altering the findings of the other steps.