Triage
Consent and Vaccinations
Assessment
Red Flags
ESI Scoring
100
The "M" in SAMPLE.
What are medications?
100
A 5 year old presents with a wound to the bottom of the foot from stepping on a board with a nail. What immunization is important to assess for?
What is tetanus?
100
What must every pediatric patient be placed into in order to ensure a complete assessment?
What is a gown?
100
Circumferential burns, patterned bruising, and bruises to the face, ears, and neck are concerning for?
What is non-accidental trauma?
100
EMS is en route with a 6 week old infant, found unresponsive in bed. CPR is in progress. What should the ESI score be for this infant?
What is ESI 1?
200
Actual age adjusted for due date.
What is gestational age?
200
A 14 year old patient presents with a laceration to the hand. His parents cannot be contacted for consent. What should the nurse do next?
What is notify the provider to determine next steps?
200
What is the minimum acceptable systolic blood pressure for a 4 year old patient?
What is 78? (2 x age +70)
200
A 2 year old child was given a cookie at a picnic. Immediately after eating it, her parents noted vomiting, swelling of her lips, and a red, raised rash to her face and neck. What condition is likely?
What is allergic reaction or anaphylaxis?
200
An 18 month old patient is brought in after a choking episode while playing with the car key remote. His xray is pictured. He is awake, alert, and babbling. What would his ESI score be?
What is ESI 2? (high risk presentation)
300
A three year old patient presents with parents complaining of "irritability". The patient is pale, inconsolable, and tachypneic. Is this patient sick, sicker, or sickest?
What is sickest?
300
A 17 year old patient presents for evaluation for abdominal pain. She states she lives on her own and is not supported financially or otherwise by any adults. What is she considered for the purposes of consent for treatment?
What is an emancipated minor?
300
What are crying without tears, sunken fontanelles, and poor skin turgor signs of?
What is dehydration?
300
Non-blanchable rash, fever, and irritability in a newborn are concerning symptoms for what life threatening condition?
What is sepsis or meningococcemia?
300
A three year old child is brought in by mom due to not wanting to use left leg. On assessment, you note swelling to the thigh, bruising in the shape of fingers to the left ankle, and scattered bruises to the torso. You activate a limited trauma team activation. What ESI score do you assign?
What is an ESI 2 (high risk situation)?
400
A 12 year old child is brought in by parents for weeks of not feeling well. They state that he is hungry all the time, drinks a ton of water, is up all night going to the bathroom, but has lost weight despite increased intake. He is awake and alert but pale, tachypneic, and you note a fruity odor to his breath. He is not in any respiratory distress. Is he sick, sicker, or sickest?
What is sicker? (Abnormal circulation)
400
A 3 year old patient presents with stridor and uncontrolled drooling. He is unvaccinated. What is the nurse concerned about?
What is epiglottitis?
400
What is the first thing you should assess in any pediatric patient with altered mentation?
What is blood sugar?
400
Substernal retractions, silent chest, see saw breathing, and drowsiness are signs of what life threatening condition?
What is respiratory failure?
400
A 6 month old child presents with parents to have child checked out due to recent respiratory infections in daycare. Child is alert with no signs of illness or distress. VS WNL. What is your ESI score?
What is an ESI 5?
500
A 9 year old patient presents with chest pain, shortness of breath, and palpitations? What recent infection should make the nurse concerned for a high risk situation and consider upgrading to an ESI 2?
What is Covid infection?
500
What federal statute mandates healthcare providers to provide services to minors, without parental consent, for government funded services such as family planning and sexually transmitted infection testing?
What is Title X?
500
A 2 week old infant presents with complaint of "poor feeding" and "fussiness". Infant was born at home with no prenatal care. Parents state she seems smaller than when she was born, tries to eat but doesn't eat well, and is always crying. She is slightly pale, tachycardic and tachypneic, and oxygen saturations are 85% on room air. The provider is concerned about a congenital heart defect. They ask you for a blood pressure assessment to assess for potential perfusion issues. What is the blood pressure assessment they ask for?
What is four limb blood pressure?
500
In a patient having a severe asthma attack, what would crepitus, paroxysmal chest movement, and worsening oxygen saturations potentially indicate?
What is pneumomediastinum or pneumothorax?
500
A 6 year old child is brought in for laceration to the face after a fall on the playground. The child is hysterical, screaming, and fighting all interventions. There are no other complaints or needs identified. What is your ESI score?
What is an ESI 3? (anticipate need for sedation/ medication prior to suturing)