PrepU Chpt 72 Emergency Nursing

Urgent

Which category of triage encompasses clients with serious health problems that are not immediately life threatening?

delayed cap refil

A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding?

jaw thrust

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?

repositioning pt's head

A nurse is establishing a patient's airway. Which action would the nurse perform first?

Ear lobe and then to the xiphoid process

A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following?

massaging the feet

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate?

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.

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.

Stage III

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in?

rectal examination

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?

Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill

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.

Encourage the client to cough forcefully.

A client presents to the ED reporting choking on a chicken bone. The client is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which action should the nurse do next?

urgent.

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?

intoxication

A client suffering from carbon monoxide poisoning would exhibit which manifestation?

Unconscious adult

A finger sweep is only to be used in which client population?

delirium

A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke?

Hypovolemia

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock?

The client agrees to detoxification, rehabilitation, and participation in an aftercare program.

A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment?

Evidence of feces

A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test?

seizures

A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following?

Tachycardia Visual hallucinations Clonus

A patient with a history of major depressive disorder is brought to the emergency department by a friend, who reports that the patient took an overdose of prescribed amitriptyline. Which of the following findings would the nurse expect to assess? Select all that apply.

pain in the left shoulder

A patient with intra-abdominal injuries is brought to the emergency department. Which of the following would most likely alert the nurse to suspect internal bleeding secondary to a ruptured spleen?

Brushing off all traces of the chemical from the patient's skin

A patient working in a chemical facility sustains a chemical burn to his arms. The chemical involved was white phosphorus. Which of the following would be the priority nursing action?

AVPU

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 reorganization phase occurs

when the incident is put into perspective. Some clients never fully recover from rape trauma

ABCDE

(airway, breathing, circulation, disability, exposure) neurologic disability

"Brightly colored clothes help to ward off bees."

A client arrives at the emergency department and is experiencing a severe allergic reaction to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed?

High-pitched noise on inhalation

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following?

Supporting the client's emotional status

A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?

Patient with extensive facial trauma Patient with laryngeal edema secondary to anaphylaxis Patient with an obstructed larynx

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.

liver

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following?

Flumazenil (Romazicon)

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?

Gunshot wound Knife-stab wound

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply.

ruptured spleen.

Pain in the left shoulder is common in a patient with bleeding from a

laceration of the liver

Pain in the right shoulder is consistent with a

Assessing the client's Glasgow Coma Scale score

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?

debriefing

The health care team in an intensive care unit have experienced a critical incident in which a young client died unexpectedly and the client's father physically attacked the senior physician treating the client. The client's father was arrested and escorted from the intensive care unit by police, against his will and in handcuffs. A critical incident stress management (CISM) staff meeting held 3 days after the incident took place. What would be the purpose for that meeting?

hypovolemic.

The nurse educator is providing orientation to a group of nurses newly hired to an intensive care unit. The group of nurses are correct in stating which is the most common type of shock managed in critical care?

4%. less than 5

The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued?

Measure the circumference of the arm.

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 analgesic medications as ordered.

The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action?

The client attempted suicide as a teenager. The client's maternal uncle committed suicide. The client had a close relationship to the accident victim.

The nurse is caring for a client in the intensive care unit who is recovering from trauma as a result of a motor vehicle accident that claimed the life of the client's friend. While the nurse is performing a dressing change on the client's surgical wound, the client states, "I don't deserve to live. I have just been thinking about ending it all." As the nurse assesses the client's imminent risk for suicide, what contributing factors need to be considered? Select all that apply.

The client requires total parenteral nutrition

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?

foot

The nurse is caring for a client with diabetes who requires a peripheral intravenous (PIV) line for antibiotic administration and to treat dehydration. The nurse must avoid inserting which type of PIV?

The client's myocardial oxygen requirements will be higher

The nurse is caring for a client with right ventricular heart failure. The nurse understands hypervolemia will have what effect on the client's heart?

cherry red skin color

When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable?

urgent

Which category of triage encompasses clients with serious health problems that are not immediately life threatening?

Naloxone hydrochloride

Which medication reverses severe respiratory depression and coma?

The denial phase

is characterized by an unwillingness to talk.

The acute disorganization phase

is characterized by shock, disbelief, guilt, humiliation, and anger.

During the heightened anxiety phase,

the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. .

brachial

A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful?

Fast-track clients require

simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician's office.

Nonurgent clients

have episodic illness that can be addressed within 24 hours without increased morbidity.

Urgent clients

have serious health problems that not immediately life threatening. They must be seen within 1 hour.

Emergent clients

have the highest priority with life-threatening conditions and they must be seen immediately.

Approximately at the patient's lips

After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position?

Run a normal saline line to keep the vein open

The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action?

Request that the pastor be present to support the family at the client bedside

The nurse in an intensive care unit is assigned to two clients. One of the clients has just passed away. The deceased client's family members have arrived to be at the client's bedside. Despite wanting to support the client's family, the nurse is must assess the other client's vital signs every 15 minutes, because the client is receiving a blood transfusion. In this situation, what is the nurse's best action?

"Are you hearing anything that is disturbing you?"

The nurse in the hospital emergency department is assessing a patient who fell while intoxicated with alcohol. The nurse is using the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale to assess the patient's need for a benzodiazepine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient?

Upside down and then rotated 180 degrees

The nurse is caring for a patient in the ED who is breathing but unconscious. In order to avoid an upper airway obstruction, the nurse is inserting an oropharyngeal airway. How would the nurse insert the airway?

Heightened anxiety phase

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?

Administer lorazepam as ordered by the health care provider

The nurse is providing care for a client who is experiencing alcohol withdrawal. The client reports, "I cannot fall or stay asleep." The nurse observes that the client is agitated, having difficulty falling asleep and crying uncontrollably, with confused speech and a tachycardic pulse. Which intervention should the nurse implement first?

Apply firm pressure over the involved area or artery.

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage?

Positioning the hands in the midline slightly above the umbilicus

When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate?

The client is assumed to have a spinal cord injury until proven otherwise.

When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind?

Show acceptance of the body by touching it, giving the family permission to touch.

Which guideline is appropriate for a nurse to implement while helping family members cope with the sudden death of a loved one?

Do not apply water to the burn

Which statement reflects the nursing management of the client with a white phosphorus chemical burn?