CH 11
A nurse assesses a client admitted with a brown recluse spider bite. Which assessment does the nurse perform to identify complications of this bite? A. Ask the client about pruritus at the bite site. B. Inspect the bite site for a bluish purple vesicle. C. Assess the extremity for redness and swelling. D. Monitor the client's temperature every 4 hours.
D
A nurse assesses a client recently bitten by a coral snake. Which assessment would the nurse complete first? A. Unilateral peripheral swelling B. Clotting times C. Cardiopulmonary status D. Electrocardiogram rhythm
C
A client admitted to the emergency department following a lightning strike. What is the priority assessment the nurse focuses on? A. Cardiopulmonary B. Integumentary C. Peripheral vascular D. Renal
A
A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? a. "I can go swimming all by myself because I am a certified lifeguard." B. "I cannot leave my toddler alone in the bathtub for even a minute." C. "I will appoint one adult to supervise the pool at all times during a party." D. "I will make sure that there is a phone near my pool in case of an emergency."
A
A primary health care provider prescribes a rewarming bath for a client who presents with Grade 3 frostbite. What action would the nurse take prior to starting this treatment? A. Administer intravenous morphine. B. Wrap the limb with a compression dressing. C. Massage the frostbitten areas. D. Assess the limb for compartment syndrome.
A
An emergency department nurse assesses a client admitted after a lightning strike. The client is awake but somewhat confused. Which assessment would the nurse complete first? A. Electrocardiogram (ECG) B. Wound inspection C. Creatinine kinase D. Computed tomography of head
A
An emergency department nurse cares for a middle-age mountain climber who is confused, ataxic, and exhibits impaired judgement. After administering oxygen, which intervention would the nurse implement next? A. Administer dexamethasone. B. Complete a mini mental state examination. C. Prepare the client for computed tomography of the brain. D. Request a psychiatric consult.
A
While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. What action would the nurse take first? A. Deliver rescue breaths. B. Wrap the client in dry blankets. C. Assess for signs of bleeding. D. Check for a carotid pulse.
A
A client resuscitated after drowning is admitted to the emergency department. What assessment findings does the nurse recognize as symptoms of a drowning? (Select all that apply.) A. Bilateral crackles B. Bradycardia C. Cyanosis of the lips D. Hypotension E. Flushed, diaphoretic skin
A,B,C,D
A nurse teaches a client who has severe allergies ways to prevent insect bites. Which statements does the nurse include in this client's teaching? (Select all that apply.) A. "Consult an exterminator to control bugs in and around your home." B. "Do not swat at insects or wasps." C. "Wear sandals whenever you go outside." D. "Keep your prescribed epinephrine auto injector in a bedside drawer." E. "Use screens in your windows and doors to prevent flying insects from entering." F. "Identify and remove potential nesting sites in your yard."
A,B,E,F
An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at highest risk for heat-related illnesses? (Select all that apply.) A. Homeless individuals B. People with substance abuse disorders C. Caucasians D. Hockey players E. Older adults F. Obese individuals
A,B,E,F
A nurse is providing health education at a community center. Which instructions does the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.) A. Seek shelter inside a building or vehicle. B. Hide under a tall tree. C. Do not take a bath or shower. D. Turn off the television. E. Remove all body piercings. F. Put down golf clubs or gardening tools
A,C,D,F
Which assessment findings would indicate to the nurse that a client has suffered from a heat stroke? (Select all that apply.) A. Confusion and bizarre behavior B. Headache and fatigue C. Hypotension D. Presence of perspiration E. Tachycardia and tachypnea F. Body temperature more than 104° F (40° C)
A,C,E,F
A nurse is in charge of a first-aid tent at an all-day outdoor sports event on a hot and humid day. A participant comes to the tent reporting a headache, weakness, and nausea. What actions would the nurse take? (Select all that apply.) A. Have the client lie down in a cool place. B. Force fluids with large quantities of plain water. C. Administer acetaminophen and send home. D. Apply cold packs to neck, arm pits, and groin. E. Encourage drinking a sports drink. F. Remove all clothing and cover with a towel.
A,D,E
An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions does the nurse include in this patient's plan of care? (Select all that apply.) A. Administer oxygen via mask or nasal cannula. B. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101° F (38.3° C). D. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. E. Obtain baseline serum electrolytes and cardiac enzymes. F. Insert an indwelling urinary catheter for urine output measurements.
A,D,E
A nurse is teaching a wilderness survival class. Which statements would the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.) A. "Wear synthetic clothing instead of cotton to keep your skin dry." B. "Drink plenty of fluids. Brandy can be used to keep your body warm." C. "Remove your hat when exercising to prevent overheating." D. "Wear sunglasses to protect skin and eyes from harmful rays." E. "Know your physical limits. Come in out of the cold when limits are reached." F. "Change your gloves and socks if they become wet."
A,D,E,F
The nurse is teaching participants in a family-oriented community center ways to prevent their older relatives and friends from getting heat-related illnesses. What information does the nurse include? (Select all that apply.) A. Use sunscreen with an SPF of at least 15 when outdoors. B. Take cool baths or showers after outdoor activities. C. Check on the older adult daily in hot weather. D. Drink plenty of liquids throughout the day. E. Wear light-colored, snugly-fitting clothing to wick sweat away.
B,C,D
A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. What action would the nurse take first? A. Reposition the client into a prone position. B. Administer warmed intravenous fluids to the client. c. Wrap the client's extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis.
B
A middle-age mountain hiker is admitted to the emergency department exhibiting a cough with pink, frothy sputum and cyanosis of lips and nail beds. What priority action would the nurse implement? A. Administer acetazolamide. B. Administer oxygen via a non-rebreather mask. C. Complete a thorough pulmonary assessment. D. Obtain arterial blood gas (ABG) specimen for analysis.
B
A nurse plans care for a client admitted with a snakebite to the right leg. With whom would the nurse collaborate? A. The facility's neurologist B. The poison control center C. The physical therapy department d. A herpetologist (snake specialist)
B
A primary health care provider prescribes diazepam to a client who was bitten by a black widow spider. The client asks, "What is this medication for?" How does the nurse respond? A. "This medication is an antivenom for this type of bite." B. "It will relieve your muscle rigidity and spasms." C. "It prevents respiratory difficulty from excessive secretions." D. "This medication will prevent respiratory failure."
B
On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. What action would the nurse take? A. Encourage the client to drink cool water or sports drinks. B. Start an intravenous line and infuse 0.9% saline solution. C. Administer acetaminophen (Tylenol) 650 mg orally. D. Encourage rest and reassess in 15 minutes.
B
After teaching a client how to prevent altitude-related illnesses, a nurse assesses the client's understanding. Which statement indicates that the client needs additional teaching? A. "If my climbing partner can't think straight, we should descend to a lower altitude." B. "I will ask my primary health care provider about medications to help prevent acute mountain sickness." C. "My partner and I will plan to sleep at a higher elevation to acclimate more quickly." D. "I will drink plenty of fluids to stay hydrated while on themountain."
C
An emergency department nurse is caring for a client who had been hiking in the mountains for the past 2 days. What are the most important indicators that a client is experiencing high-altitude pulmonary edema (HAPE)? (Select all that apply.) A. Ataxia B. Confusion C. Crackles in both lung fields D. Decreased level of consciousness E. Persistent dry cough F. Reports "feeling hung over"
C,E
While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible. What action would the nurse take first? A. Elevate the site and notify the person's next of kin. B. Remove the stinger with tweezers and encourage rest. C. Administer diphenhydramine and apply ice. D. Administer an epinephrine autoinjector and call 911.
D
