A triage nurse finds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?

Choice A Reason:

Provide assistance with ambulation: Patients with cerebellar tumors often experience ataxia, which is a lack of muscle coordination affecting voluntary movements such as walking and balance. Assisting with ambulation is crucial to prevent falls and ensure the patient’s safety. The cerebellum plays a significant role in motor control, and damage to this area can severely impair a patient’s ability to move safely. Therefore, providing assistance with ambulation is a priority to prevent injury and promote mobility.

Choice B Reason:

Facilitate retention of facts by repeating instructions: While repeating instructions can be beneficial for patients with cognitive impairments, it is not the primary concern for a patient with a cerebellar tumor. The main issues with cerebellar tumors are related to motor control and balance. Although cognitive support is important, ensuring physical safety through assistance with ambulation takes precedence.

Choice C Reason:

Place the client in a darkened room: Placing a patient in a darkened room might help with symptoms like photophobia (sensitivity to light), but it does not address the primary concerns associated with cerebellar tumors, such as balance and coordination. This action does not directly contribute to the patient’s immediate safety and mobility needs.

Choice D Reason:

Speak slowly and clearly: Clear communication is always important in nursing care, especially for patients who may have difficulty understanding due to neurological issues. However, for a patient with a cerebellar tumor, the immediate priority is to address motor dysfunction and prevent falls. Speaking slowly and clearly is supportive but not the primary action needed to ensure the patient’s safety.

Choice A Reason:

Decreasing leg strength is a common symptom of Guillain-Barré syndrome (GBS) and indicates the progression of muscle weakness. While it is concerning and should be monitored, it is not as immediately critical as respiratory complications.

Choice B Reason:

Decreasing voice volume can indicate involvement of the cranial nerves and potential respiratory muscle weakness, which can lead to respiratory failure. This is an urgent finding that requires immediate attention to prevent respiratory complications.

Choice C Reason:

Decreased deep tendon reflexes are a hallmark of GBS and are expected in the progression of the disease. While they should be documented and monitored, they do not require immediate reporting unless accompanied by other critical symptoms.

Choice D Reason:

Decreased sensation in the arms is another common symptom of GBS due to peripheral nerve involvement. It should be monitored, but it is not as urgent as signs of respiratory compromise.