The nurse assessing a patient who walked into the emergency department decides the patient is in no acute distress. Which of the following did the nurse assess in this patient?

Question

1. Able to ambulate, breathing without difficulty, possible right arm/shoulder pain because holding arm bent and close to body
2. Limping and walking with the assistance of a possible family member or friend
3. Gasping for breath and holding a bloody tissue next to nose
4. Calling for help while limping with the use of a cane

Answer 1

Able to ambulate, breathing without difficulty, possible right arm/shoulder pain because holding arm bent and close to body

Rationale: Triage begins with an "across the room" assessment and takes into consideration the primary assessment components of airway, breathing, circulation, and disability. Of the individuals described, the patient who is able to ambulate, breathe without difficulty, but might have right arm/shoulder discomfort would be the one with the least amount of distress. The other patients would have more distress or disability and would need faster intervention.