Emergency Nursing- Brunner

7. A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action? A) Check the patient's blood glucose level. B) Assess for a documented history of major depression. C) Determine whether the patient has ingested a corrosive substance. D) Arrange for assessment of serum potassium levels.

Ans: A

8. The paramedics bring a patient who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim? A) Respect the patient's privacy during assessment. B) Shave all pubic hair for laboratory analysis. C) Place items for evidence in plastic bags. D) Bathe the patient before the examination.

Ans: A

29. A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply. A) Dysrhythmias B) Hypothermia C) Hypotension D) Hyperglycemia E) Delirium

Ans: A, C, E

13. A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient? A) Assessing the patient's oral temperature frequently B) Ensuring continuous ECG monitoring C) Massaging the patient's skin surfaces to promote circulation D) Administering bronchodilators by nebulizer

Ans: B

1. Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? A) A patient with a blunt chest trauma with some difficulty breathing B) A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar C) A patient with a possible fractured tibia with adequate pedal pulses D) A patient with an acute onset of confusion

Ans: A

19. A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the patient's frostbite? A) Immerse affected extremities in water slightly above normal body temperature. B) Immerse the patient's frostbitten extremities in the warmest water the patient can tolerate. C) Gently massage the patient's frozen extremities in between water baths. D) Perform passive range-of-motion exercises of the affected extremities to promote circulation.

Ans: A

24. A patient is admitted to the ED after being involved in a motor vehicle accident. The patient has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care? A) Control the patient's hemorrhage. B) Assess for cognitive effects of the injury. C) Splint the patient's fractures. D) Assess the patient's neurologic status.

Ans: A

27. The triage nurse is working in the ED. A homeless person is admitted during a blizzard with complaints of being unable to feel his feet and lower legs. Core temperature is noted at 33.2∞C (91.8∫F). The patient is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurse's priority in the care of this patient? A) Addressing the patient's hypothermia B) Addressing the patient's frostbite in his lower extremities C) Addressing the patient's alcohol intoxication D) Addressing the patient's malnutrition

Ans: A

30. The nurse is caring for a patient admitted with a drug overdose. What is the nurse's priority responsibility in caring for this patient? A) Support the patient's respiratory and cardiovascular function. B) Provide for the safety of the patient. C) Enhance clearance of the offending agent. D) Ensure the safety of the staff.

Ans: A

34. The ED nurse is planning the care of a patient who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal? A) Encouraging the patient to gain a sense of control over his or her life B) Collecting sufficient evidence to secure a criminal conviction C) Helping the patient understand that this will not happen again D) Encouraging the patient to verbalize what happened during the assault

Ans: A

37. A patient is brought to the ED by two police officers. The patient was found unconscious on the sidewalk, with his face and hands covered in blood. At present, the patient is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the patient in restraints. What action should the nurse perform when the patient is restrained? A) Frequently assess the patient's skin integrity. B) Inform the patient that he is likely to be charged with assault. C) Avoid interacting with the patient until the restraints are removed. D) Take the opportunity to perform a full physical assessment.

Ans: A

38. An 83-year-old patient is brought in by ambulance from a long-term care facility. The patient's symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage. Why would this be true? A) Older adults may have an altered response to treatment. B) Older adults are often reluctant to adhere to prescribed treatment. C) Older adults have difficulty giving a health history. D) Older adults often stigmatize their peers who use the ED.

Ans: A

4. A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action? A) Perform a rapid physical assessment. B) Initiate health education. C) Perform diagnostic imaging. D) Establish the circumstances of the accident.

Ans: A

14. A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A) Absence of bruising at contusion sites B) Rapid pulse and decreased capillary refill C) Increased BP with narrowed pulse pressure D) Sudden diaphoresis

Ans: B

15. A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patient's peritoneum, the nurse should anticipate what diagnostic test? A) Radiograph B) Computed tomography (CT) scan C) Complete blood count (CBC) D) Barium swallow

Ans: B

2. The nurse observes that the family members of a patient who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family? A) Anxiety and denial B) Remorse and guilt C) Anger D) Grief

Ans: B

3. A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what? A) Liver B) Small bowel C) Stomach D) Large bowel

Ans: B

31. A patient is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the patient's cardiopulmonary status, the nurse should prepare to perform what intervention? A) Administer a bolus of lactated Ringer's. B) Administer naloxone hydrochloride (Narcan). C) Insert an indwelling urinary catheter. D) Perform a focused neurologic assessment.

Ans: B

32. A patient is being treated for bites that she suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action? A) Apply a dressing saturated with chlorhexidine. B) Wash the bites with soap and water. C) Arrange for the patient to receive a hepatitis B vaccination. D) Assess the patient's immunization history.

Ans: B

35. The ED nurse admitting a patient with a history of depression is screening the patient for suicide risk. What assessment question should the nurse ask when screening the patient? A) "How would you describe your mood over the past few days?" B) "Have you ever thought about taking your own life?" C) "How do you think that your life is most likely to end?" D) "How would you rate the severity of your depression right now on a 10-point scale?"

Ans: B

39. An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patients' acuity as well as what other variable? A) The likelihood of a repeat visit to the ED in the next 7 days B) The resources that the patient is likely to require C) The patient's or insurer's ability to pay for care D) Whether the patient is known to ED staff from previous visits

Ans: B

5. The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses who provide care in a desert region. The educator should describe what sign or symptom? A) Hypertension with a wide pulse pressure B) Anhidrosis C) Copious diuresis D) Cheyne-Stokes respirations

Ans: B

9. A patient with a history of major depression is brought to the ED by her parents. Which of the following nursing actions is most appropriate? A) Noting that symptoms of physical illness are not relevant to the current diagnosis B) Asking the patient if she has ever thought about taking her own life C) Conducting interviews in a brief and direct manner D) Arranging for the patient to spend time alone to consider her feelings

Ans: B

22. A patient is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply. A) Ascites B) Rebound tenderness C) Changes in bowel sounds D) Muscular rigidity E) Copious diarrhea

Ans: B, C, D

11. You are a floor nurse caring for a patient with alcohol withdrawal syndrome. What would be an appropriate nursing action to minimize the potential for hallucinations? A) Engage the patient in a process of health education. B) Administer opioid analgesics as ordered. C) Place the patient in a private, well-lit room. D) Provide television or a radio as therapeutic distraction

Ans: C

17. A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions? A) Insert an oropharyngeal airway. B) Perform the jaw thrust maneuver. C) Perform endotracheal intubation. D) Perform a cricothyroidotomy.

Ans: C

18. A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient? A) Ambulate the patient to expel flatus. B) Place the patient in a high Fowler's position. C) Immobilize the patient on a backboard. D) Place the patient in a left lateral position.

Ans: C

20. A patient with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the patient's injuries? A) Myocardial infarction B) Hypoglycemia C) Hemorrhage D) Peritonitis

Ans: C

25. A patient with multiple trauma is brought to the ED by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this patient's care? A) Intubating the patient B) Notifying family members C) Ensuring IV access D) Delivering specimens to the laboratory

Ans: C

28. A patient is brought to the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temperature of 40.1∫C (104.2∞F). What would be the priority nursing action for this patient? A) Monitor cardiovascular effects. B) Administer antipyretics. C) Ensure airway and ventilation. D) Prevent seizure activity.

Ans: C

36. A patient is brought to the ED by family members who tell the nurse that the patient has been exhibiting paranoid, agitated behavior. What should the nurse do when interacting with this patient? A) Keep the patient in a confined space. B) Use therapeutic touch appropriately. C) Give the patient honest answers about likely treatment. D) Attempt to convince the patient that his or her fears are unfounded.

Ans: C

40. A 23-year-old woman is brought to the ED complaining of stomach cramps, nausea, vomiting, and diarrhea. The care team suspects food poisoning. What is the key to treatment in food poisoning? A) Administering IV antibiotics B) Assessing immunization status C) Determining the source and type of food poisoning D) Determining if anyone else in the family is ill

Ans: C

6. A patient is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The patient is alert and oriented. What is the care team's most appropriate treatment? A) Administering syrup of ipecac B) Performing a gastric lavage C) Giving milk to drink D) Referring to psychiatry

Ans: C

10. A triage nurse is talking to a patient when the patient begins choking on his lunch. The patient is coughing forcefully. What should the nurse do? A) Stand him up and perform the abdominal thrust maneuver from behind. B) Lay him down, straddle him, and perform the abdominal thrust maneuver. C) Leave him to get assistance. D) Stay with him and encourage him, but not intervene at this time.

Ans: D

12. An obtunded patient is admitted to the ED after ingesting bleach. The nurse should prepare to assist with what intervention? A) Prompt administration of an antidote B) Gastric lavage C) Administration of activated charcoal D) Helping the patient drink large amounts of water

Ans: D

16. A patient is brought to the ER in an unconscious state. The physician notes that the patient is in need of emergency surgery. No family members are present, and the patient does not have identification. What action by the nurse is most important regarding consent for treatment? A) Ask the social worker to come and sign the consent. B) Contact the police to obtain the patient's identity. C) Obtain a court order to treat the patient. D) Clearly document LOC and health status on the patient's chart.

Ans: D

21. A patient who has been diagnosed with cholecystitis is being discharged home from the ED to be scheduled for surgery later. The patient received morphine during the present ED admission and is visibly drowsy. When providing health education to the patient, what would be the most appropriate nursing action? A) Give written instructions to patient. B) Give verbal instructions to one of the patient's family members. C) Telephone the patient the next day with verbal instructions. D) Give verbal and written instructions to patient and a family member.

Ans: D

23. A patient who attempted suicide being treated in the ED is accompanied by his mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following action? A) Refer the family to psychiatry in order to provide them with support. B) Explore the causes of the patient's suicide attempt with the family. C) Encourage the family to participate in the bedside care of the patient. D) Ensure that the family receives appropriate crisis intervention services.

Ans: D

26. A patient has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the patient's bladder is distended. What is the nurse's most appropriate action? A) Withhold fluids from the patient. B) Perform intermittent urinary catheterization. C) Insert a narrow-gauge indwelling urinary catheter. D) Await orders following the urologist's assessment.

Ans: D

33. A nurse is caring for a patient who has been the victim of sexual assault. The nurse documents that the patient appears to be in a state of shock, verbalizing fear, guilt, and humiliation. What phase of rape trauma syndrome is this patient most likely experiencing? A) Reorganization phase B) Denial phase C) Heightened anxiety phase D) Acute disorganization phase

Ans: D