ADH Exam 2 (ER and legal/ethical)
A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply. Talk with the family about the client having "passed on." Provide sedation to family members as needed. Ask the family if they would like to view the body. Provide a private place for the family to be together. Allow the family to express their emotions freely.
Ask the family if they would like to view the body. Provide a private place for the family to be together. Allow the family to express their emotions freely. Explanation: When providing care to a family experiencing the sudden death of a member, the nurse would take the relatives to a private place where they can be together to grieve. In addition, the nurse would encourage the family to view the body if they wish and allow members to support each other and express their emotions freely. Euphemisms such as "passing on" or "going to a better place" should be avoided. Sedation is avoided because it may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and prevent prolonged depression.
A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this patient should expect the physician to order what drug for the management of the patients diarrhea? A) Zithromax B) Sandostatin C) Levaquin D) Biaxin
B Feedback: Therapy with octreotide acetate (Sandostatin), a synthetic analogue of somatostatin, has been shown to be effective in managing chronic severe diarrhea. Zithromax, Levaquin, and Biaxin are not used to treat chronic severe diarrhea.
The nurse is caring for a client who is agitated and confused. The client is persistently trying to get out of bed and attempted to remove the peripheral IV. The nurse has attempted to re-orient the client; however, this was not effective in de-escalating the client's agitation. The client yells, "I am going to punch you in the face!" What is the nurse's next action? Call security personnel to assist Adminster antipsychotic medication Apply physical restraints Move out of the client's view
Call security personnel to assist Explanation: Clients at risk for harming staff members require specific interventions. It is important to first notification of security and administration of the potential for violence. Although medication and physical restraints maybe required, the nurse will not be able to carry out these interventions in a safe manner independently. The nurse should first call for security personnel to assist, all other interventions can be carried out with the support of trained staff. When a client is agitated and has the potential to be violent, they should not be left unattended. Moving out of the client's view can lead to further agitation for the client and increase the risk for escalating to violence.
The nurse is caring for a terminally ill client in the intensive care unit that is on life support measures. The family members are opposed in their decision to take the client off of life support. What option does the nurse discuss with the nurse manager? Ask the family to go out of the unit and make a decision that is final. Contact the ethics committee for their input. Have the health care provider inform the family that they are not responsible for the decision. Take the client off of life support when the family is not present.
Contact the ethics committee for their input. Explanation: The ethics committee may be called on to act as an advocate for clients who no longer are mentally capable of making their own decisions. Ethics committees are a valuable resource for reviewing difficult cases and helping ensure a careful and unbiased decision. The nurse is not practicing within the scope of practice by taking the client off of life support. The nurse does not mandate to the health care provider decisions that should be made. It is nontherapeutic for the nurse to ask the family to go out and make a decision.
The nurse is to administer a potassium supplement to the client. The nurse does not check the potassium level prior to administering the medication and later finds that the potassium level was at a critical high. What principle has this nurse violated? Beneficence Nonmaleficence Autonomy Fidelity
Nonmaleficence Explanation: Nonmaleficence is the duty to do no harm to the client. For instance, if a nurse fails to check an order for an unusually high dose of insulin and administers it, he or she has violated the principle of nonmaleficence. Beneficence is the duty to do good for the clients assigned to the nurse's care. The nurse has a duty to remove wrist restraints whenever possible (removing a harm) and to help the client regain independence (promoting and doing good). Fidelity is the duty to maintain commitments of professional obligations and responsibilities. Autonomy refers to a client's right to self-determination or the freedom to make choices without opposition.
Nursing students are reviewing information about anaphylactic reactions and their possible causes. The students demonstrate understanding of this information when they identify which of the following as a common cause? Select all that apply. Insect stings Medications Latex Eggs Shellfish Green vegetables
Insect stings Medications Latex Eggs Shellfish Explanation: Common causes of anaphylactic reactions include insect stings, medications (eg, penicillin, iodinated-contrast materials), latex, insect stings, eggs, peanuts, and shellfish. Green vegetables typically are not associated with anaphylaxis.
Assessment, the first of five steps in the nursing process, begins with initial patient contact. What activities by the nurse are included in this component of the nursing process? (Select all that apply.) Interviewing and obtaining a nursing history Observing for altered symptomatology Collecting and analyzing data Evaluation of the patient's response to a medication Developing outcome criteria
Interviewing and obtaining a nursing history Observing for altered symptomatology Collecting and analyzing data Explanation: Assessment data are gathered through the health history (including an interview) and the physical assessment. In addition, ongoing monitoring is crucial to remain aware of changing patient needs and the effectiveness of nursing care. The health history is conducted to determine a person's state of wellness or illness and is best accomplished as part of a planned interview. Evaluating a patient's response to a medication is part of the evaluation step of the nursing process. Developing outcome criteria is part of the planning step of the nursing process.
Which of the following is a true statement about critical thinking according to Alfaro-LeFevre (2010)? It makes judgments based on conjecture. It is based on the medical model. It considers only the client's needs. It is guided by professional standards and codes of ethics.
It is guided by professional standards and codes of ethics. Explanation: Critical thinking is guided by professional standards and codes of ethics. It is based on principles of the nursing process and scientific methods. Critical thinking makes judgments based on evidence rather than conjecture. It considers client, family, and community needs.
A client, 50 years old, is admitted for treatment of a gastric tumor. The client asks the nurse, "Do you think I have cancer?" Which response by the nurse would be most therapeutic? "Your physician can tell you more about it." "Most women your age have some kind of cancer." "We don't know for sure until you undergo more tests." "You sound concerned about what the physicians will tell you."
"You sound concerned about what the physicians will tell you." Explanation: Reflection is a therapeutic communication tool that validates the nurse's understanding of what the client is saying and signifies empathy, interest, and respect for the client.
Maslow's Hierarchy of Needs
(level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization
oxygen is administered until the carboxyhemoglobin level is less than what percent?
5%
A clinic nurse is caring for a patient admitted with AIDS. The nurse has assessed that the patient is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication? A) HIV encephalopathy B) B-cell lymphoma C) Kaposis sarcoma D) Wasting syndrome
A Feedback: HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, and motor functions. The other listed complications do not normally have cognitive and behavioral manifestations.
An HIV-infected patient presents at the clinic for a scheduled CD4+ count. The results of the test are 45 cells/mL, and the nurse recognizes the patients increased risk for Mycobacterium aviumcomplex (MAC disease). The nurse should anticipate the administration of what drug? A) Azithromycin B) Vancomycin C) Levofloxacin D) Fluconazole
A Feedback: HIV-infected adults and adolescents should receive chemoprophylaxis against disseminatedMycobacterium avium complex (MAC disease) if they have a CD4+ count less than 50 cells/L. Azithromycin (Zithromax) or clarithromycin (Biaxin) are the preferred prophylactic agents. Vancomycin, levofloxacin, and fluconazole are not prophylactic agents for MAC.
A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply. A) Current medication regimen B) Identification of patients support system C) Immune system function D) Genetic risk factors for HIV E) History of sexual practices
A, B, C, E Feedback: Nursing assessment includes numerous focuses, including identification of medication use, support system, immune function and sexual history. HIV does not have a genetic component.
A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply. A) Serum albumin level B) Weight history C) White blood cell count D) Body mass index E) Blood urea nitrogen (BUN) level
A, B, D, E Feedback: Nutritional status is assessed by obtaining a dietary history and identifying factors that may interfere with oral intake, such as anorexia, nausea, vomiting, oral pain, or difficulty swallowing. In addition, the patients ability to purchase and prepare food is assessed. Weight history (i.e., changes over time); anthropometric measurements; and blood urea nitrogen (BUN), serum protein, albumin, and transferrin levels provide objective measurements of nutritional status. White cell count is not a typical component of a nutritional assessment.
A client has been diagnosed with cardiac dysfunction and admitted to a health care center. The nurse notices that the client's ankles and feet are swollen. Using critical thinking skills, which nursing intervention does the nurse know to perform next? Assess client for dependent edema Weigh client daily at the same time Organize activities to provide frequent rest periods Assess oxygen saturation level
Assess client for dependent edema Explanation: Initial assessments of swollen ankles and feet are symptoms of dependent edema. Hence, the priority assessment method adopted by the nurse should be oriented toward gathering as much relevant information as possible related to edema. Measuring the client's weight, organizing activities to provide frequent rest periods, and assessing oxygen saturation level are also nursing interventions to be used under appropriate circumstances.
The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities effectively in a client experiencing a trauma. Which action is completed by the nurse when implementing the "D" element of this method? Assessing the client's Glasgow Coma Scale score Managing hypothermia Providing cervical spine protection Undressing the client quickly
Assessing the client's Glasgow Coma Scale score Explanation: The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. While implementing the D element, the nurse determines neurologic disability by assessing neurologic function using the Glasgow Coma Scale and performing a motor and sensory evaluation of the spine. A quick neurologic assessment may be performed using the AVPU mnemonic: A, alert: is the client alert and responsive? V, verbal: does the client respond to verbal stimuli? P, pain: does the client respond only to painful stimuli? U, unresponsive: is the client unresponsive to all stimuli, including pain? The other interventions are not included in this element of the primary survey.
A hospital nurse has experienced percutaneous exposure to an HIV-positive patients blood as a result of a needlestick injury. The nurse has informed the supervisor and identified the patient. What action should the nurse take next? A) Flush the wound site with chlorhexidine. B) Report to the emergency department or employee health department. C) Apply a hydrocolloid dressing to the wound site. D) Follow up with the nurses primary care provider.
B Feedback: After initiating the emergency reporting system, the nurse should report as quickly as possible to the employee health services, the emergency department, or other designated treatment facility. Flushing is recommended, but chlorhexidine is not used for this purpose. Applying a dressing is not recommended. Following up with the nurses own primary care provider would require an unacceptable delay.
A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote significant weight gain in AIDS patients by increasing body fat stores? A) Advera B) Momordicacharantia C) Megestrol D) Ranitidine
C Feedback: Megestrol acetate (Megace), a synthetic oral progesterone preparation, promotes significant weight gain. In patients with HIV infection, it increases body weight primarily by increasing body fat stores. Advera is a nutritional supplement that has been developed specifically for people with HIV infection and AIDS. Momordicacharantia (bitter melon) is given as an enema and is part of alternative treatment for HIV/AIDS. Ranitidine prevents ulcers.
The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the nurses most appropriate action? A) Assess the patient for additional signs and symptoms of Kaposis sarcoma. B) Review the patients most recent viral load and CD4+ count. C) Place the patient on respiratory isolation and inform the physician. D) Perform oral suctioning to reduce the patients risk for aspiration.
C Feedback: These signs and symptoms are suggestive of tuberculosis, not Kaposis sarcoma; prompt assessment and treatment is necessary. There is no indication of a need for oral suctioning and the patients blood work will not reflect the onset of this opportunistic infection.
When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable? Cherry red skin color Headache Confusion Palpitations
Cherry red skin color Explanation: Skin color can range from pink or cherry-red to cyanotic and pale is not a reliable sign. In clients with carbon monoxide poisoning, central nervous system signs such as headache and confusion predominate. Palpitations also may occur.
A terminally ill client asks the nurse, "Am I dying?" The family has asked the health care team not to disclose the client's terminal illness. What is the best action by the nurse with the client's question? Select all that apply. Communicate the client's wishes to the family. Consult with the health care provider Provide correct information to the client. Tell the client, "You will be fine." Have the health care provider disclose the information the client requires.
Communicate the client's wishes to the family. Consult with the health care provider Provide correct information to the client.
A client presents to the ED following a motor vehicle collision. The client is suspected of having internal hemorrhage. The nurse assesses the client for signs and symptoms of shock. Which are signs and symptoms of shock? Select all that apply. Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill Increasing urine volume
Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill Explanation: Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume.
A patients current antiretroviral regimen includes nucleoside reverse transcriptase inhibitors (NRTIs). What dietary counseling will the nurse provide based on the patients medication regimen? A) Avoid high-fat meals while taking this medication. B) Limit fluid intake to 2 liters a day. C) Limit sodium intake to 2 grams per day. D) Take this medication without regard to meals.
D Feedback: Many NRTIs exist, but all of them may be safely taken without regard to meals. Protein, fluid, and sodium restrictions play no role in relation to these drugs.
A client is to be discharged from an acute care facility after treatment for pneumonia. The nurse notes that the client's lungs are clear and denies shortness of breath. The nurse's actions reflect which step of the nursing process? Analysis Evaluation Assessment Data collection
Evaluation Explanation: Evaluation, the final step of the nursing process, allows the nurse to determine the client's response to the nursing interventions and the extent to which the objectives have been achieved. The other answers are incorrect because they are not the correct phase of the nursing process.
A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test? Red blood cell count of 50,000/mm3 White blood cell count of 300/mm3 Absence of bile Evidence of feces
Evidence of feces Explanation: A diagnostic peritoneal lavage is considered positive if there is bile, feces, or food in the specimen, a red blood cell count greater than 100,000/mm3, and a white blood cell count greater than 500/mm3.
A patient arrives at the emergency department after taking more than 20 lorazepam tablets. Which of the following would the nurse anticipate that the patient would be given to reverse the effects of the drug? Naloxone Flumazenil Diazepam N-aceytlcysteine
Flumazenil Explanation: Lorazepam is a nonbarbiturate sedative whose effects are reversed with flumazenil. Naloxone is used to reverse the effects of opioids. Diazepam is used to treat seizures associated with drug overdose. It would not be used here, because it is in the same class as lorazepam and concurrent administration would add to the patient's overdose state. N-acetylcysteine is the antidote for acetaminiophen toxicity.
A patient is brought to the emergency department after being locked outside of her house in the frigid weather for several hours. The nurse suspects that the patient has sustained frostbite of her hand based on which of the following findings? Hand that appears pink with some white spotting Hand that is firm to palpation Hand that is insensitive to touch Hand that is cool with pale nailbeds
Hand that is insensitive to touch Explanation: Indicators of frostbite include an extremity that is hard, cold, and insensitive to touch and appears white or mottled blue-white.
The decision-making part of the problem-solving activities of nurses has become increasingly multifaceted and requires critical thinking. There are many reasons why this is so in today's health care arena. Choose all that apply. Increasingly complex issues faced by nurses Advanced technology Greater acuity of clients A younger population Complex disease processes
Increasingly complex issues faced by nurses Advanced technology Greater acuity of clients Complex disease processes Explanation: In today's health care arena, nurses face increasingly complex issues and situations resulting from advanced technology, greater acuity of clients in both hospital and community settings, an aging population, and complex disease processes, as well as ethical issues and cultural factors. The decision-making part of the problem-solving activities of nurses has become increasingly multifaceted and requires critical thinking.
A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? Head tilt-chin lift Jaw-thrust Abdominal thrust Seldinger
Jaw-thrust Explanation: If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.
Based on the nurse's knowledge of the increased risk for bleeding in a client undergoing chemotherapy or radiation, which of the following interventions does the nurse need to include in the client's plan of care? Select all that apply. Monitoring the platelet count Monitoring for signs of abnormal bleeding Instructing the client to use a soft toothbrush Instructing the client to use an electric razor Instructing the client to add low-dose aspirin to daily medication regimen Increasing the patient's injections for pain control
Monitoring the platelet count Monitoring for signs of abnormal bleeding Instructing the client to use a soft toothbrush Instructing the client to use an electric razor Explanation: Utilizing critical thinking skills, the nurse knows to implement individualized interventions to reduce the client's risk of bleeding. Hence, the nurse must frequently assess platelet counts, monitor for signs of abnormal bleeding, and instruct the client and family about ways to minimize bleeding, such as using a soft toothbrush and/or an electric razor. Medications that may interfere with clotting, such as aspirin, should be avoided, and blood draws and injections should be kept to a minimum.
A nurse is providing an in-service program for fellow emergency nurses about hypothermia and rewarming methods used. The nurse determines that the presentation was successful when the group identifies which of the following as a passive active rewarming method? Cardiopulmonary bypass Over-the-bed heaters Forced warm air blankets Warmed humidified oxygen by ventilator
Over-the-bed heaters Explanation: Passive active rewarming uses over-the-bed heaters to the extremities and increases blood flow to the acidotic, anaerobic extremities. Cardiopulmonary bypass and warm humidified oxygen by ventilator are examples of active core (internal) rewarming methods. Forced warm air blankets are examples of active external rewarming methods.
A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority? Protecting himself or herself Securing the area Gaining control of the situation Providing care to the injured
Protecting himself or herself Explanation: If gunfire occurs in the emergency department, self-protection is the priority. Security officers and police must gain control of the situation first and then care is provided to the injured.
A client is confused about advance directives and asks the nurse to explain them. What information will the nurse include in client teaching about advance directives? Select all that apply. They provide information about client wishes for health care situations. They list the client's belongings and who should get what after the client dies. They may contain a living will. They address financial information that may assist health care providers in decision making. They explain the client's philosophy of life.
They provide information about client wishes for health care situations. They may contain a living will. Explanation: Advance directives are legal documents that specify a client's wishes before hospitalizations and provide nurses valuable information for potential decision making. A living will is one type of advance directive; another is a durable power of attorney for health care.
A finger sweep is only to be used in which client population? Conscious adult Unconscious adult Child Adolescent
Unconscious adult Explanation: A finger sweep should be used only in the unconscious adult client. This action draws the tongue away from the back of the throat and away from any foreign body that may be lodged there. A finger sweep should not be done on a conscious adult, child, or adolescent.
A client presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the client into which category? Emergent Urgent Nonurgent Psychological support
Urgent Explanation: Clients triaged as urgent have serious health problems that are not immediately life threatening. They must be seen within 1 hour. The emergent category is for clients who have the highest priority conditions that are life-threatening and they must be seen immediately. Nonurgent is for clients who have episodic illness that can be addressed within 24 hours without increased morbidity. Clients in the less urgent category must be reassessed at least every 60 minutes and do not have serious health problems.
Alfaro-LeFevre
Who summarized that critical thinking: -Entails purposeful, goal-directed thinking -Aims to make judgments based on evidence (fact) rather than conjecture (guesswork) -Is based on the principles of science and scientific method -Requires strategies that maximize human potential and compensate for problems caused by human nature.
Alfaro-LeFevre's characteristics of critical thinkers
active thinker, fair-minded, open-minded, persistent, empathetic, independent in thought, good communicators, honest, organized and systematic, proactive, flexible, realistic, humble, cognizant of rules of logic, curious and insightful, creative and committed to excellence
A client has just returned to the unit following abdominal surgery and is in significant pain. According to the nursing process, how frequently will the nurse perform assessments on this client? as often as needed once upon arrival and 1hour later once upon arrival and every 2 hours afterward twice per shift
as often as needed Explanation: Assessment is an important, recurring nursing activity that continues as long as a need for healthcare exists. During assessment, the nurse methodically obtains data about the client's health, illness, and change in condition.
The nurse is developing a client's care plan. What activity best exemplifies the assessment phase of the nursing process? assist with ambulation give a complete bed bath determines the client has a pulse rate of 88 bpm check blood pressure daily
determines the client has a pulse rate of 88 bpm Explanation: The assessment phase of the nursing process includes a health history and physical examination. The pulse rate is obtained during a physical assessment. The remaining options are not data obtained during the assessment phase, but steps in the implementation phase of the nursing process.
what is the most common type of shock managed in critical care?
hypovolemic
A client with newly diagnosed diabetes requests information about how to give an injection. What is the best communication technique the nurse can use with the client? providing a URL for a website that demonstrates proper injection technique demonstrating the proper injection technique informing about the proper injection technique reflecting the client's feelings about his question
informing about the proper injection technique Explanation: The therapeutic communication technique of informing allows the nurse to provide the client with information relevant to the client's well being. The website and in-person demonstration of the technique are teaching tools, but not a therapeutic comunication technique. Using reflection is not the best communication technique for the situation.
Which type of nursing diagnosis identifies potential problems that may arise due to the client's disease, condition, or situation? risk actual health promotion syndrome
risk Explanation: Risk nursing diagnoses identify potential problems and use the stem "risk for" as in Risk for Impaired Skin Integrity related to inactivity. The actual diagnosis identifies an existing problem such as Urinary Retention or Anxiety. The health promotion diagnosis is a judgment of a client's motivation and behavior to increase well-being. The syndrome diagnosis describes specific diagnoses that occur as a group.
Which statement reflects the nursing management of the client with a white phosphorus chemical burn? Immediately drench the skin with running water from a shower, hose, or faucet Alternate applications of water and ice to the burn Do not apply water to the burn Wash off the chemical using warm water, then flush the skin with cool water
Do not apply water to the burn Explanation: Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or deepening of the burn.
Which of the following is a cognitive or mental activity that nurses use in critical thinking? Using bias to achieve goals Drawing on past clinical experiences and knowledge to explain what is happening Setting priorities with broad time constraints Determining nurse-specific outcomes
Drawing on past clinical experiences and knowledge to explain what is happening Explanation: Intellectual skills used in critical thinking include drawing on past clinical experiences and knowledge to explain what is happening, priority setting with timely decision making, and determining client-specific outcomes. Bias is not used to achieve goals.
A client has designated her daughter as a person to make healthcare decisions for the client if he is not able to do so. What type of advance directive is this considered? Power of attorney Do-not-resuscitate order (DNR) Living will Durable power of attorney (DPOA) for healthcare
Durable power of attorney (DPOA) for healthcare Explanation: A client may designate another person to be the DPOA for healthcare or healthcare proxy. This person has the authority to make healthcare decisions for the client if he or she is no longer competent or able to make these decisions. A general power of attorney does not give that designated person the ability to make healthcare decision. In DNR order,the client wishes to have no resuscitative action taken if he or she experiences a cardiac or respiratory arrest. A living will is a document that states a client's wishes regarding healthcare if he or she is terminally ill.
The nurse is caring for a victim of a sexual assault. The client is fearful and experiencing flashbacks. The nurse recognizes that the client is experiencing which phase of the psychological reaction to rape? Heightened anxiety phase Acute disorganization phase Denial phase Reorganization phase
Heightened anxiety phase Explanation: During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some clients never fully recover from rape trauma.
The nurse is administering antivenin to a patient who was bitten on the arm by a poisonous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after? Administer diphenhydramine (Benadryl). Administer cimetidine (Tagamet). Measure the circumference of the arm. Assess peripheral pulses.
Measure the circumference of the arm. Explanation: Before administering antivenin and every 15 minutes thereafter, the circumference of the affected part is measured. Premedication with diphenhydramine (Benadryl) or cimetidine (Tagamet) may be indicated, because these antihistamines may decrease the allergic response to antivenin. Antivenin is administered as an IV infusion whenever possible, although intramuscular administration can be used.
The nurse is preparing to transfer a client from the ICU to a medical unit in the hospital. To ensure consistent communication regarding the client's care needs to the receiving unit, in what sequence of steps should the nurse organize the report? 1 Obtain the client's health record 2 State the client's admission date and current diagnosis 3 Provide a brief statement of current concerns 4 Give the client's pertinent medical history 5 Provide the most recent vital signs and assessment findings 6 Give recommendations for what needs to be done for the client
Obtain the client's health record State the client's admission date and current diagnosis Provide a brief statement of current concerns Give the client's pertinent medical history Provide the most recent vital signs and assessment findings Give recommendations for what needs to be done for the client Explanation: When using the SBAR tool for consistent communication in health care settings, the nurse should organize sharing information about the client by including what the receiving unit needs to know about the (S)ituation, (B)ackground, (A)ssessment and (R)ecommendations. The nurse should first have the chart in hand before making the phone call, and be sure they can readily communicate all the following: Briefly state the issue or problem: what it is, when it happened (or how it started) and how severe it is. Give the signs and symptoms that cause concern. The nurse should then provide the date of admission and current medical diagnoses. Next, the nurse must give most recent vital signs and any recent changes in the systems assessment. For example, the nurse may need to communicate that the client had become constipated over the past 24 hours. Finally, it is important for the nurse to provide recommendations about what actions are need to be taken in the client's care. The nurse should state what they think should be done to address any identified client problems.
A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply. Patient with extensive facial trauma Patient with a lumbar spine injury Patient with laryngeal edema secondary to anaphylaxis Patient who is bleeding from the chest Patient with an obstructed larynx
Patient with extensive facial trauma Patient with laryngeal edema secondary to anaphylaxis Patient with an obstructed larynx Explanation: Cricothyroidotomy is used in emergencies when endotracheal intubation is either not possible or contraindicated. Examples include airway obstruction from extensive maxillofacial trauma, cervical spine injury, laryngospasm, laryngeal edema after an allergic reaction or extubation, hemorrhage into neck tissue, and obstruction of the larynx.
A client is brought to the emergency department with suspected genitourinary injury. The nurse prepares the client for insertion of an indwelling urinary catheter for bladder decompression and urine output monitoring. The nurse reviews the client's medical record to ensure that which of the following has been completed? Computed tomography scan Rectal examination Diagnostic peritoneal lavage Bladder ultrasound
Rectal examination Explanation: In a client with a suspected genitourinary injury, an indwelling urinary catheter is inserted for bladder decompression and urine output monitoring only after a rectal examination has been completed. Computed tomography or bladder ultrasound are not necessary. A diagnostic peritoneal lavage is a backup procedure for evaluating intraperitoneal injury
The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason? The client will require intravenous access for three days The client requires total parenteral nutrition The client requires infusion of intravenous antibiotics The client requires infusion of a dextrose 5% water (D5W)
The client requires total parenteral nutrition Explanation: For a patient who requires total parenteral nutrition (TPN), a central intravenous line is required due to the length of time the client will require the infusion as well as the nature of the solution itself. A large vein is required to safely infuse TPN. For this reason, a central line is needed. A peripheral intravenous line is safe to used when IV access is required under six days. Beyond this time, either a new peripheral IV will need to be inserted. If it is known in advance that IV treatment will last beyond six days, the client's health care provider will order the placement of a central intravenous line. Intravenous antibiotics can be administered peripherally unless the course is longer than six days. D5W is an intravenous solution that can be administered either peripherally or centrally. The nature of this IV solution would not determine which type of IV access the client requires.
A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose? Delayed Emergent Immediate Urgent
Urgent Explanation: A basic and widely used triage system that had been in use for many years utilized three categories: emergent, urgent, and nonurgent. In this system, emergent patients had the highest priority, urgent patients had serious health problems but not immediately life-threatening ones, and nonurgent patients had episodic illnesses.
A hospital board of directors decides to close a pediatric burn treatment center (BTC) that annually admits 50 patients and to open a treatment center for terminally ill AIDS patients (with an expected annual admission of 200). This decision means that the nearest BTC for children is now 300 miles away. What example of ethical reasoning is this decision consistent with? A formalist approach Obligation or duty "The means justifies the end" Utilitarianism
Utilitarianism Explanation: One classic theory in ethics is teleologic theory or consequentialism, which focuses on the ends or consequences of actions. The best-known form of this theory, utilitarianism, is based on the concept of "the greatest good for the greatest number." Another theory in ethics is the deontologic or formalist theory, which argues that ethical standards or principles exist independently of the ends or consequences. Beneficence is the obligation or duty to do good and the active promotion of benevolent acts (e.g., goodness, kindness, charity).
A nurse using critical thinking interprets data and determines appropriate interventions. What factor will affect the nurse's ability to employ critical thinking with data interpretation? the nurse's gender the nurse's personal biases the date of the client's admission the client's admission diagnosis
the nurse's personal biases Explanation: Nurses using critical thinking will consider the possibility of personal bias when interpreting data. The other options such as the nurse's gender and the client's admission date and diagnosis are not appropriate considerations with using critical thinking.
Which intellectual skill is used by nurses when thinking critically? Utilizing bias to achieve goals Supporting evidence with facts Priority setting with broad time constraints Determining nurse-specific outcomes
upporting evidence with facts Explanation: Intellectual skills used in critical thinking include supporting evidence with facts, setting priorities through timely decision making, and determining client-specific outcomes. Bias is not used to achieve goals.
