Bioterrorism and Emergency Disaster
Ongoing evaluation of a patient with blunt liver trauma includes serial measurements of which of the following laboratory values? A. hematocrit B. lipase C. troponin D. amylase
A. hematocrit As the patient can continue to bleed internally from blunt liver trauma without overt external evidence, the ongoing laboratory value that would demonstrate this potentially life-threatening problem is the hematocrit. Lipase and amylase are measures for pancreatic injuries. Troponin is a measure for cardiac injury
Following emergency endotracheal intubation, you must verify tube placement and secure the tube. List in order the steps that are required to perform this function? a. Obtain an order for a chest x-ray to document tube placement. b. Secure the tube in place. c. Auscultate the chest during assisted ventilation. d. Confirm that the breath sounds are equal and bilateral. A. C D B A B. A B C D C. D C B A D. B C D A
A Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the mid-epigastric area, tube placement must be corrected immediately. Securing the tube is appropriate while waiting for the x-ray study.
In the work setting, what is your primary responsibility in preparing for disaster management that includes natural disasters or bioterrorism incidents? A. Knowledge of the agency's emergency response plan B. Awareness of the signs and symptoms for potential agents of bioterrorism C. Knowledge of how and what to report to the CDC D. Ethical decision-making about exposing self to potentially lethal substances
A In preparing for disasters, the RN should be aware of the emergency response plan. The plan gives guidance that includes roles of team members, responsibilities, and mechanisms of reporting. Signs and symptoms of many agents will mimic common complaints, such as flu-like symptoms. Discussions with colleagues and supervisors may help the individual nurse to sort through ethical dilemmas related to potential danger to self.
The best indication of adequate tissue perfusion in a patient in shock is A. a urine output of 30 mL/h. B. an oxygen saturation of greater than 70%. C. a central venous pressure of 10 cm H2O. D. a capillary refill time of greater than 2 seconds.
A. a urine output of 30 mL/h. Urine output is the best indicator of adequate tissue perfusion. It is desired to have an oxygen saturation of much greater than 70% and a capillary refill time of LESS than 2 seconds.
A victim of near-drowning who was initially thought to be "OK" arrives at the emergency department several hours later with increasing shortness of breath. Respirations are 36/min, and crackles (rales) and wheezes are present. The patient receives 100% oxygen via nonrebreathing mask. Arterial blood gas analysis yields the following values: pH 7.30; PaCO2 40 mm Hg; PaO2 50 mm Hg; and HCO3- 18 mEq/L The emergency nurse should anticipate the need to first A. prepare for intubation of the trachea. B. decrease the amount of oxygen. C. administer a bronchodilator. D. administer 50 mEq of sodium bicarbonate.
A. prepare for intubation of the trachea. Submersion injuries frequently progress to respiratory failure (ARDS). Using the ABC method of assessment and the results of the blood gas analysis on 100% oxygen, this patient is not adequately breathing. To better provide support for oxygenation, the emergency nurse should prepare for intubation.
When caring for a patient with a suspected blunt cardiac injury, the emergency nurse should first prepare to administer A. supplemental oxygen. B. a narcotic analgesic. C. lidocaine (Xylocaine). D. sublingual nitroglycerin (Anginine).
A. supplemental oxygen. Blunt cardiac injury, formerly referred to as cardiac contusion or myocardial contusion, is best diagnosed with an echocardiogram and is treated symptomatically. Monitor the patient's cardiac rhythm, administer supplemental oxygen, and treat the patient's musculoskeletal chest pain. Dysrhythmias (premature ventricular complexes) are common, but are rarely treated unless they interfere with hemodynamic stability.
You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform. a. Perform the chin lift or jaw thrust maneuver. b. Establish unresponsiveness. c. Initiate cardiopulmonary resuscitation (CPR). d. Call for help and activate the code team. e. Instruct a nursing assistant to get the crash cart. A. A B C E D B. B D A C E C. C A B E D D. D C B E A E. E C D B A
B Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives.
A patient in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated for this patient. a. Secure/start two large-bore IVs with normal saline b. Use the chin lift or jaw thrust method to open the airway. c. Assess for spontaneous respirations d. Give supplemental oxygen per mask. e. Obtain a full set of vital signs. f. Remove patient's clothing. g. Insert a Foley catheter if not contraindicated. A. C B D A E G F B. C B D A E F G C. A D F G E C B D. A D F G C E B
B For a multiple trauma victim, many interventions will occur simultaneously as team members assist in the resuscitation. Methods to open the airway such as the chin lift or jaw thrust can be used simultaneously while assessing for spontaneous respirations. However, airway and oxygenation are priority. Starting IVs for fluid resuscitation is part of supporting circulation. (EMS will usually establish at least one IV in the field.) Nursing assistants can be directed to take vitals and remove clothing. Foley catheter is necessary to closely monitor output.
You are assigned to telephone triage. A patient who was stung by a common honey bee calls for advice, reports pain and localized swelling, but denies any respiratory distress or other systemic signs of anaphylaxis. What is the action that you should direct the caller to perform? A. Call 911. B. Remove the stinger by scraping. C. Apply a cool compress. D. Take an oral antihistamine
B The stinger will continue to release venom into the skin, so prompt removal of the stinger is advised. Cool compresses and antihistamines can follow. The caller should be further advised about symptoms that require 911 assistance.
A patient who has been in a motorcycle crash is awake, alert, and oriented, but complains of severe neck pain. A cross-table lateral radiograph demonstrates a fracture of the second and third cervical vertebrae. Shortly after the radiograph is taken, the patient experiences respiratory arrest. Appropriate initial management of the airway should consist of A. endotracheal intubation. B. administration of oxygen by a nasal cannula. C. jaw-thrust maneuver and ventilation with a bag-mask device. D. head-tilt maneuver and placement of an oropharyngeal airway.
C. jaw-thrust maneuver and ventilation with a bag-mask device. The jaw-thrust maneuver should be used as the basic airway management in any patient with a suspected cervical spine injury without tilting the head. Endotracheal intubation will be done, but is not the first action to be taken. Core Curriculum for Critical Care Nursing, 6th ed., p. 10
An adult patient sustains blunt trauma to the abdomen in a motor vehicle crash. The patient refuses to allow any invasive treatments. Initial assessment reveals an ecchymotic area in the left upper quadrant. The emergency nurse should A. allow the patient to leave after signing a medical release form. B. request an order to sedate the patient. C. assess the patient's neurological status. D. obtain consent from a relative for treatment.
C. assess the patient's neurological status. A rational, competent adult can refuse any treatment. The first step is to establish the patient's ability to understand the consequences of refusing treatment. Due to the mechanism of injury, this patient should be evaluated for the presence of a head injury
A patient has experienced blunt abdominal trauma from a motor vehicle accident. The nurse should explain to the patient the purpose of a. magnetic resonance imaging (MRI). b. ultrasonography. c. peritoneal lavage. d. nasogastric (NG) tube placement.
Correct Answer: B Rationale: If intra-abdominal bleeding is suspected, focused abdominal ultrasonography is obtained to look for intraperitoneal bleeding. MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intra-abdominal bleeding.
Four victims of an automobile crash are brought by ambulance to the emergency department. The triage nurse determines that the victim who has the highest priority for treatment is the one with a. severe bleeding of facial and head lacerations. b. an open femur fracture with profuse bleeding. c. a sucking chest wound. d. absence of peripheral pulses.
Correct Answer: C Rationale: Most immediate deaths from trauma occur because of problems with ventilation, so the patient with a sucking chest wound should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries has lacerations only. The other two patients also need rapid intervention but do not have airway or breathing problems.
In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN? A. Talk to a community group about water safety issues. B. Stabilize the cervical spine for an unconscious drowning victim. C. Remove wet clothing and cover the victim with a warm blanket. D. Monitor an asymptomatic near-drowning victim
D The asymptomatic patient is currently stable but should be observed for delayed pulmonary edema, cerebral edema, or pneumonia. Teaching and care of critical patients is an RN responsibility. Removing clothing can be delegated to a nursing assistant.
A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness. This patient should be prioritized into which category? A. High urgent B. Urgent C. Non-urgent D. Emergent
D Chest pain is considered an emergent priority, which is defined as potentially life-threatening. Patients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones). Non-urgent conditions can wait for hours or even days. (High urgent is not commonly used; however, in 5-tier triage systems, High urgent patients fall between emergent and urgent in terms of the time lapsing prior to treatment).
In a multiple-trauma victim, which assessment finding signals the most serious and life-threatening condition? A. A deviated trachea B. Gross deformity in a lower extremity C. Decreased bowel sounds D. Hematuria
A A deviated trachea is a symptoms of tension pneumothorax. All of the other symptoms need to be addressed, but are of lesser priority.
A soldier in the military is exposed to a nerve agent. The nurse takes what immediate action? A. Prepare to inject atropine B. Flush eyes with water C. Apply a steroid to the skin D. Induce vomiting
A. Prepare to inject atropine Rationale: Atropine is given to block the attachment of acetylcholine to receptor sites, preventing overstimulation and death.
A teenager arrives by private car. He is alert and ambulatory, but this shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that that they were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration? A. "There was a lot of blood and we used three bandages." B. "He pulled the stick out, just now, because it was hurting him." C. "The stick was really dirty and covered with mud." D. "He's a diabetic, so he needs attention right away."
B An impaled object may be providing a tamponade effect, and removal can precipitate sudden hemodynamic decompensation. Additional history including a more definitive description of the blood loss, depth of penetration, and medical history should be obtained. Other information, such as the dirt on the stick or history of diabetes, is important in the overall treatment plan, but can be addressed later.
A client is suspected of exposure to inhaled anthrax. The nurse assesses for which initial symptoms? A. Headache, blurred vision, and generalized aches B. Difficulty swallowing, cramping, and diarrhea C. Fever, persistent cough, and dyspnea D. Skin lesions that develop into black scabs
C Rationale: Fever, persistent cough, and dyspnea all are initial symptoms of inhaled anthrax.
The nurse should monitor a client exposed to ionizing rations for which symptom(s) of radiation sickness? A. Constipation B. Headaches and muscular pain C. Nausea and vomiting D. Blurred vision
C Rationale: Immediate symptoms of ionizing radiation include nausea, vomiting, and diarrhea.
A 67-year-old patient who has fallen from a ladder is transported to the emergency department by ambulance. The patient is unconscious on arrival and accompanied by family members. During the primary survey of the patient, the nurse should a. assess a full set of vital signs. b. obtain a Glasgow Coma Scale score. c. attach a cardiac ECG monitor. d. ask about chronic medical conditions.
Correct Answer: B Rationale: The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.
A patient has been brought to the emergency department with a gunshot wound to the abdomen. In obtaining a history of the incident to determine possible injuries, the nurse asks a. "Where did the incident occur?" b. "What direction did the bullet enter the body?" c. "How long ago did the incident happen?" d. "What emergency care was started at the scene?"
Correct Answer: B Rationale: The entry point and direction of the bullet will help to predict the type of injuries the patient has. The other information is not as useful in determining which diagnostic studies and care are needed immediately.
A prisoner, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis? A. Risk for Injury related to seizures B. Risk for Other-Directed Violence related to hallucinations C. Risk for Situational Low Self-esteem related to police custody D. Risk for Nutritional Deficit related to chronic alcohol abuse
A The patient demonstrates neurologic hyperactivity and is on the verge of a seizure. Patient safety is the priority. The patient needs chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) will also be ordered to address the other problems. The other diagnoses are pertinent but not as immediate.
The physician has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which of the following would be appropriate to delegate to the nursing assistant? A. Assist the child to remove outer clothing. B. Advise the parent to use acetaminophen instead of aspirin. C. Explain the need for cool fluids. D. Prepare and administer a tepid bath
A The nursing assistant can assist with the removal of the outer clothing, which allows the heat to dissipate from the child's skin. Advising and explaining are teaching functions that are the responsibility of the RN. Tepid baths are not usually performed because of potential for rebound and shivering.
A tearful parent brings a child to the ED for taking an unknown amount of children's chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be immediately reported to the physician? A. The ingested children's chewable vitamins contain iron. B. The child has been treated several times for ingestion of toxic substances. C. The child has been treated several times for accidental injuries. D. The child was nauseated and vomited once at home
A Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and hepatic failure. Deferoxamine is an antidote that can be used for severe cases of iron poisoning. Other information needs additional investigation, but will not change the immediate diagnostic testing or treatment plan.
The emergency medical service (EMS) has transported a patient with severe chest pain. As the patient is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the nursing assistant? A. Chest compressions B. Bag-valve mask ventilation C. Assisting with oral intubation D. Placing the defibrillator pads
A Nursing assistants are trained in basic cardiac life support and can perform chest compressions. The use of the bag-valve mask requires practice and usually a respiratory therapist will perform this function. The nurse or the respiratory therapist should provide PRN assistance during intubation. The defibrillator pads are clearly marked; however, placement should be done by the RN or physician because of the potential for skin damage and electrical arcing.
You are giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic violence. What is your priority intervention for this patient? A. Transportation arrangements to a safe house B. Referral to a counselor C. Advice about contacting the police D. Follow-up appointment for injuries
A Safety is a priority for this patient, and she should not return to a place where violence could occur. The other options are important for the long term management of this care.
You are caring for a victim of frostbite to the feet. Place the following interventions in the correct order. a. Apply a loose, sterile, bulky dressing. b. Give pain medication. c. Remove the victim from the cold environment. d. Immerse the feet in warm water 100o F to 105o F (40.6o C to 46.1o C) A. A D C B B. C B A D C. C B D A D. C A B D
C The victim should be removed from the cold environment first, and then the rewarming process can be initiated. It will be painful, so give pain medication prior to immersing the feet in warmed water.
In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? A. Complete set of vital signs B. Palpation and auscultation of the abdomen C. Brief neurologic assessment D. Initiation of pulse oximetry
C A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey.
You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients. a. An ambulatory, dazed 25-year-old male with a bandaged head wound b. An irritable infant with a fever, petechiae, and nuchal rigidity c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity d. A 50-year-old female with moderate abdominal pain and occasional vomiting A. A B D C B. B A D C C. C D B A D. C B A D
b An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24 - 48 hours if necessary.
Hypovolemic shock is most likely to occur secondary to a fracture of the A. humerus. B. femur. C. sternum. D. tibia.
B. femur. A patient may lose up to 1500 mL of blood in a femur fracture. This blood loss correlates with Class II - hemorrhagic shock
Neurogenic shock is most likely indicated if a patient has a blood pressure of A. 86/50 mm Hg and a pulse of 52/min. B. 100/80 mm Hg and a pulse of 146/min. C. 120/74 mm Hg and a pulse of 110/min. D. 180/98 mm Hg and a pulse of 45/min.
A. 86/50 mm Hg and a pulse of 52/min. Neurogenic shock is a result of injury to the medullary vasomotor center or to the spinal cord. Resultant block of the sympathetic nervous system leaves the parasympathetic nervous system unopposed. Signs and symptoms of neurogenic shock include decreased blood pressure with an associated bradycardia
When an unexpected death occurs in the ED, which of the following tasks is most appropriate to delegate to the nursing assistant? A. Escort the family to a place of privacy. B. Go with the organ donor specialist to talk to the family. C. Assist with postmortem care. D. Assist the family to collect belongings
C Postmortem care requires some turning, cleaning, lifting, etc., and the nursing assistant is able to assist with these duties. The RN should take responsibility for the other tasks to help the family begin the grieving process. In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained.
An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse's first week on the job. Which area of the ED is the most appropriate assignment for the nurse? A. Trauma team B. Triage C. Ambulatory or fast track clinic D. Pediatric medicine team
C The fast track clinic will deal with relatively stable patients. Triage, trauma, and pediatric medicine should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment.
A patient sustains an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to the LPN/LVN? A. Gently cleanse the amputated digits with Betadine solution. B. Place the amputated digits directly into ice slurry. C. Wrap the amputated digits in sterile gauze moistened with saline. D. Store the amputated digits in a solution of sterile normal saline
C The only correct intervention is C. the digits should be gently cleansed with normal saline, wrapped in sterile gauze moistened with saline, and placed in a plastic bag or container. The container is then placed on ice.
An anxious 24-year-old college student complains of tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take? A. Notify the physician immediately. B. Administer supplemental oxygen. C. Have the student breathe into a paper bag. D. Obtain an order for an anxiolytic medication
C The patient is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen and medication may be needed if other causes are identified.
An occupational health professional is conducting a class on risks of occupational exposure to inhalation of anthrax. Should an exposure occur, the employees are told they should receive which medication? A. Penicillin and vancomycin B. Erythromycin and vancomycin C. Ciprofloxacin and doxycycline D. Tetracycline and ampicillin
C Rationale: The FDA-approved combination therapy for inhalation of anthrax is ciprofloxacin and doxycycline.
A patient who sustains a severe pulmonary contusion as a result of a motor vehicle crash should be expected to have A. steady, substernal pain and no radiographic changes. B. hypotension and muffled breath sounds. C. local areas of wheezing and radiographic changes. D. neck vein distention and diminished breath sounds on the affected side.
C. local areas of wheezing and radiographic changes. In a pulmonary contusion, blood extravasates into the lung tissue, causing alveolar and interstitial edema. This may cause localized wheezing and may be evident on radiograph, though usually 12 or more hours after the event.
A man who briefly lost consciousness after a motor vehicle crash is alert and oriented upon arrival at the emergency department. The patient states that he is fine except for an abrasion where his head hit the door frame of the automobile. The patient complains of blurred vision 1 hour later. The emergency nurse should first A. assess visual acuity. B. obtain orthostatic vital signs. C. repeat the neurologic assessment. D. obtain blood glucose measurement.
C. repeat the neurologic assessment. Considering this patient's mechanism of injury, a closed head injury should be suspected. Increased intracranial pressure due to edema or intracranial bleeding may be manifested by symptoms such as visual disturbances, decreased level of consciousness or vomiting; therefore, a follow-up neurological assessment is warranted. There is no reason to suspect that this patient would have orthostatic changes in vital signs. Assessing visual acuity and obtaining a blood glucose measurement may be indicated if the patient's neurological status is unchanged but they would not be the priority.
During the primary assessment of a patient with multiple trauma, the nurse observes that the patient's right pedal pulses are absent and the leg is swollen. The nurse's first action should be to a. initiate isotonic fluid infusion through two large-bore IV lines. b. send blood to the lab for a complete blood count (CBC). c. finish the airway, breathing, circulation, disability survey. d. assess further for a cause of the decreased circulation.
Correct Answer: A Rationale: The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a CBC is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.
A patient is brought to the hospital in cardiac arrest by emergency personnel who are performing resuscitation. The spouse arrives as the patient is taken into a treatment room and asks to stay with the patient. The nurse should a. have the spouse wait outside the treatment room with a designated staff member to provide emotional support. b. bring the spouse into the room and ensure him or her that a member of the team will explain the care given and answer questions. c. explain that the presence of family members is distracting to staff and might impair the resuscitation efforts. d. advise the spouse that if the resuscitation effort is unsuccessful, the memories may have an adverse impact on grievinG
Correct Answer: B Rationale: Family members and patients report benefits from family presence during resuscitation efforts, so the nurse should try to accommodate the spouse. Having the spouse wait outside the room is not as supportive to the spouse or patient. It would be inappropriate to imply that the spouse's presence would have adverse consequences for the patient. Family members do not report problems with grieving caused by being present during resuscitation efforts.
A triage nurse in a busy emergency department assesses a patient who complains of 6/10 abdominal pain and states, "I had a temperature of 104.6º F (40.3º C) at home." The nurse's first action should be to a. tell the patient that it may be several hours before being seen by the doctor. b. assess the patient's current vital signs. c. obtain a clean-catch urine for urinalysis. d. ask the health care provider to order a nonopioid analgesic medication for the patient.
Correct Answer: B Rationale: The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be needed, but vital signs will provide the nurse with more useful data for triage. The health care provider will not order a medication before assessing the patient.
When caring for a patient with head and neck trauma after a motorcycle accident, the emergency department nurse's first action should be to a. suction the mouth and oropharynx. b. immobilize the cervical spine. c. administer supplemental oxygen. d. obtain venous access.
Correct Answer: B Rationale: When there is a risk of spinal cord injury, the nurse's initial action is immobilization of the cervical spine during positioning of the head and neck for airway management. Suctioning, supplemental oxygen administration, and venous access are also necessary after the cervical spine is protected by immobilization.
During the primary assessment of a trauma victim, the nurse determines that the patient has a patent airway. The next assessment by the nurse should be to a. check the patient's level of consciousness. b. examine the patient for any external bleeding. c. observe the patient's respiratory effort. d. palpate for the presence of peripheral pulses.
Correct Answer: C Rationale: Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions are also part of the initial survey but are not accomplished as rapidly as the assessment of breathing.
It is the summer season, and patients with signs and symptoms of heat-related illness present in the ED. Which patient needs attention first? A. An elderly person complains of dizziness and syncope after standing in the sun for several hours to view a parade B. A marathon runner complains of severe leg cramps and nausea. Tachycardia, diaphoresis, pallor, and weakness are observed. C. A previously healthy homemaker reports broken air conditioner for days. Tachypnea, hypotension, fatigue, and profuse diaphoresis are observed. D. A homeless person, poor historian, presents with altered mental status, poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown.
D The homeless person has symptoms of heat stroke, a medical emergency, which increases risk for brain damage. Elderly patients are at risk for heat syncope and should be educated to rest in cool area and avoid future similar situations. The runner is having heat cramps, which can be managed with rest and fluids. The housewife is experiencing heat exhaustion, and management includes fluids (IV or parenteral) and cooling measures. The prognosis for recovery is good.
An intoxicated patient presents with slurred speech, mild confusion, and uncooperative behavior. The patient is a poor historian but admits to "drinking a few on the weekend." What is the priority nursing action for this patient? A. Obtain an order for a blood alcohol level. B. Contact the family to obtain additional history and baseline information. C. Administer naloxone (Narcan) 2 - 4 mg as ordered. D. Administer IV fluid support with supplemental thiamine as ordered
D The patient presents with symptoms of alcohol abuse and there is a risk for Wernicke's syndrome, which is caused by a thiamine deficiency. Multiples drug abuse is not uncommon; however, there is nothing in the question that suggests an opiate overdose that requires naloxone. Additional information or the results of the blood alcohol level are part of the total treatment plan but should not delay the immediate treatment.
These patients present to the ED complaining of acute abdominal pain. Prioritize them in order of severity. a. A 35-year-old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating b. A 11-year-old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days c. A 40-year-old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past week d. A 56-year-old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour A. A D B C B. B C D A C. C B D A D. D B C A
D The patient with a pulsating mass has an abdominal aneurysm that may rupture and he may decompensate suddenly. The 11-year-old boy needs evaluation to rule out appendicitis. The woman needs evaluation for gallbladder problems that appear to be worsening. The 35-year-old man has food poisoning, which is usually self-limiting.
The nurse should plan to assess soldiers who might have been exposed to nerve gas agents for which symptoms? A. Malaise and hemorrhaging B. Memory loss and fatigue C. Fever and headaches D. Convulsions and loss of consciousness
D Rationale: Overstimulation of the neurotransmitter acetylcholine causes convulsions and loss of consciousness within seconds.