Part I: Emergency Department (ED) SKINNY Reasoning ALL ANSWERS 100% CORRECT FALL-2022 LATEST SOLUTION AID GRADE A+

Primary Concept Infection/Immunity Interrelated Concepts (In order of emphasis) ● Clinical judgment NCLEX Client Need Categories Covered in Case Study NCSBN Clinical Judgment Model Covered in Case Study Safe and Effective Care Environment Step 1: Recognize Cues ● Management of Care Step 2: Analyze Cues ● Safety and Infection Control Step 3: Prioritize Hypotheses Health Promotion and Maintenance Step 4: Generate Solutions Psychosocial Integrity Step 5: Take Action Physiological Integrity Step 6: Evaluate Outcomes ● Basic Care and Comfort ● Pharmacological and Parenteral Therapies ● Reduction of Risk Potential ● Physiological Adaptation Initial Triage Assessment in ED Present Problem: John Taylor is a 68-year-old African-American male with a history of type II diabetes and hypertension who came to the emergency department (ED) triage window because he felt crummy; complaining of a headache, runny nose, feeling more weak, “achy all over” and hot to the touch and sweaty the past two days. When he woke up this morning, he no longer felt hot but began to develop a persistent “nagging cough” that continued to worsen throughout the day. He has difficulty “catching his breath” when he gets up to go the bathroom. John is visibly anxious and asks, “Do I have that killer virus that I hear about on the news?” Personal/Social History: John lives in a large metropolitan area that has had over three thousand confirmed cases of COVID-19. He has been married to Maxine, his wife of 45 years and is retired police officer and active in his local church. 1. What data from the histories are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)