Chapter 68: Emergency
A 71-yr-old woman arrives in the emergency department after ingesting 8 g of acetaminophen (Tylenol). Which question is most important for the nurse to ask? "Do you feel like you have a fever?" "What time did you take the medication?" "Have you tried to commit suicide before?" "Are you experiencing any abdominal pain?"
"What time did you take the medication?" Acetaminophen will bind to activated charcoal and pass through the gastrointestinal tract without being absorbed. Activated charcoal is most effective if administered within 1 hour of ingestion of acetaminophen and other select poisons.
A nurse is performing triage in the emergency department. Which patient should the nurse see first? A 18-yr-old patient with type 1 diabetes mellitus who has a 4-cm laceration on right leg A 32-yr-old patient with drug overdose who is unresponsive with a poor respiratory effort A 56-yr-old patient with substernal chest pain who is diaphoretic with shortness of breath A 78-yr-old patient with right hip fracture who is confused; blood pressure is 98/62 mm Hg
A 32-yr-old patient with drug overdose who is unresponsive with a poor respiratory effort The patient with a drug overdose is unstable and needs to be seen immediately. Patient with chest pain (possible myocardial infarction) should be seen second. Patient with hip fracture should be seen third. Patient with laceration is the most stable and should be seen last.
An 18-yr-old man who fell through the ice on a pond near his farm was admitted to the emergency department with somnolence. Vital signs are blood pressure of 82 mm Hg systolic with Doppler, respirations of 9 breaths/min, and core temperature of 90°F (32.2°C). The nurse should anticipate which intervention? Active core rewarming Immersion in a hot bath Rehydration and massage Passive external rewarming
Active core rewarming Active internal or core rewarming is used for moderate to severe hypothermia and involves the application of heat directly to the core. Immersion in a hot bath, rehydration, and massage are not appropriate interventions in the treatment of severe hypothermia. Passive rewarming is used in mild hypothermia.
The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas with temperatures near 100°F (37.7°C) for the past 2 weeks. When assessing the patient, the nurse finds hypotension, body temperature of 104°F (40°C), dry and ashen skin, and neurologic symptoms. What treatments should the nurse anticipate (select all that apply.)? Administer 100% O2. Immerse in an ice bath. Administer cool IV fluids. Cover the patient to prevent chilling. Administer acetaminophen (Tylenol). Administer chlorpromazine for shivering.
Administer 100% O2. Administer cool IV fluids. Administer chlorpromazine for shivering. The patient is experiencing heatstroke. Treatment focuses first on stabilizing the patient's ABC and rapidly reducing the core temperature. Administration of 100% O2 compensates for the patient's hypermetabolic state. Cooling the body with IV fluids is effective. Immersion in an ice bath will cause shivers that increase core temperature, so a cool water bath should be used for conductive cooling. Removing the clothing, covering the patient with wet sheets, and placing the patient in front of a fan will cause evaporative cooling. If shivering ensues, treatment with chlorpromazine is indicated. Shivering increases core temperature due to the heat generated by muscle activity. Excessive covers will not be used. Acetaminophen will not be effective because the increase in temperature is not related to infection.
A 47-yr-old man who was lost in the mountains for 2 days is admitted to the emergency department with cold exposure and a core body temperature of 86.6ºF (30.3ºC). Which nursing action is most important? Administer warmed IV fluids. Position patient under a radiant heat lamp. Place an air-filled warming blanket on the patient. Immerse the extremities in a water bath (102° to 108°F [38.9° to 42.2°C]).
Administer warmed IV fluids. A patient with a core body temperature of 86.6ºF (30.3ºC) has moderate hypothermia. Active core rewarming is used for moderate to severe hypothermia and includes administration of warmed IV fluids (109.4ºF [43ºC]). Patients with moderate to severe hypothermia should have the core warmed before the extremities to prevent after drop (or further drop in core temperature). This occurs when cold peripheral blood returns to the central circulation. Use passive or active external rewarming for mild hypothermia. Active external rewarming involves fluid-filled warming blankets or radiant heat lamps. Immersion of extremities in a water bath is indicated for frostbite.
An 18-yr-old young woman has been admitted to the emergency department after ingesting an entire bottle of chewable multivitamins in a suicide attempt. The nurse should anticipate which intervention? Induced vomiting Whole-bowel irrigation Administration of activated charcoal Administration of fresh frozen plasma
Administration of activated charcoal Among the most common treatments for poisoning is the administration of activated charcoal. Induced vomiting is not typically indicated, and there is no need for plasma administration. Whole-bowel irrigation may be used as an adjunct therapy later in treatment, but the use of activated charcoal is central to the treatment of poisonings.
A mass casualty incident was identified on a nearby freeway. Which patient would likely be designated "red" during triage at the site? An individual who is distraught at the violence of the incident An individual who has experienced an open arm fracture from falling debris An individual who is not expected to survive a crushing head and neck wound An individual whose femoral artery has been severed and is bleeding profusely
An individual whose femoral artery has been severed and is bleeding profusely Red indicates a life-threatening injury requiring immediate intervention, such as severe bleeding. Emotional trauma would not warrant a "red" designation, and a fracture would likely be deemed "yellow," urgent but not life threatening. Those not expected to survive are categorized "blue." "Black" identifies the dead.
A nurse in the emergency department is working triage. Which patient assessment findings would indicate immediate care is required? Shortened and externally rotated leg Inability to swallow and move the left arm Warm, edematous, reddened and painful calf Yellow sputum and pain with deep inspiration
Inability to swallow and move the left arm Inability to swallow and move the left arm suggests the patient is experiencing a stroke. A CT scan is indicated within 25 minutes of arrival to determine ischemic versus hemorrhagic origin, which will delineate available treatments. The warm, edematous, reddened and painful calf suggests deep vein thrombosis. Although not an immediate threat, there is a risk of pulmonary emboli. A shortened and externally rotated leg suggests a hip fracture. A patient with yellow sputum and pain with deep inspiration suggest a pneumonia that may require hospitalization or could be treated as an outpatient.
A nurse teaches the emergency department staff about their roles during a mass casualty incident. Which primary responsibility is expected of all licensed and unlicensed health care staff? Notify local, state, and national authorities. Assist security personnel to patrol the area. Learn the hospital emergency response plan. Contact the American Red Cross for assistance.
Learn the hospital emergency response plan. All health care providers must be prepared for a mass casualty incident. The priority responsibility is to know the agency's emergency response plan.
A male patient is brought into the emergency department with multiple stab wounds to the legs, one stab wound to the left abdomen, and gang tattoos on both arms. He refused to identify his attacker and then loses consciousness. Police identify him as the assailant in the fatal stabbing of another man. What is the nurse's priority? Guard locked access doors. Maintain patient safety from revenge. Maintain personal and work place safety. Attain open patient airway and breathing.
Maintain personal and work place safety. The nurse's priority is to maintain personal and work place safety. Violence can erupt in the emergency department when treating gang members if the rival gang seeks revenge, or the patient's gang members seek to protect the patient with their presence. Staff members can be victims of that violence, so they should maintain a safe work environment by seeking law enforcement and security assistance in maintaining safety for the staff and the patient. ABCs are the usual priority, but this situation does not show any problem with the patient's airway or breathing.
Which assessment parameter will the nurse address during the secondary survey of a patient in triage? Blood pressure and heart rate Patency of the patient's airway Neurologic status and level of consciousness Presence or absence of breath sound and quality of breathing
Neurologic status and level of consciousness Vital signs are considered to be a part of the secondary survey in the triage process. Airway, breathing, circulation, and a brief neurologic assessment are components of the primary survey that is done to identify life-threatening conditions.
Which guideline for the assessment of intimate partner violence (IPV) should the emergency nurse follow? Patients should be routinely screened for family and IPV. Patients whom the nurse deems high risk should be assessed for IPV. All female patients and patients under 18 should be assessed for IPV. Patients should be assessed for IPV provided corroborating evidence exists.
Patients should be routinely screened for family and IPV. In the emergency department, the nurse needs to screen for family and IPV. Routine screening for this risk factor is required. Such assessment should not be limited to female, high-risk, or young patients, and evidence need not be present to screen for the problem.
Three days after experiencing a series of tick bites, a patient presents to the emergency department. Which manifestation would indicate the patient is experiencing tick paralysis? Respiratory distress Aggression and frequent falls Decreased level of consciousness Fever and necrosis at the bite sites
Respiratory distress A classic manifestation of tick paralysis is flaccid ascending paralysis, which develops over 1 to 2 days. Without tick removal, the patient dies as respiratory muscles become paralyzed. Aggression, decreased level of consciousness, fever, and necrosis at the bite sites are not characteristic of the problem
Students are having an end of the semester party, which includes drinking alcohol, having snacks, and swimming. A student was found floating in the pool. Which action by first responders is most important? Immobilizing the cervical spine Evacuating water from the lungs Securing the airway and providing ventilation Establishing IV access and infusing warmed fluids
Securing the airway and providing ventilation Aggressive resuscitation efforts (e.g., airway and ventilation management), especially in the prehospital phase, improve survival of drowning victims. Initial evaluation involves assessment of airway, cervical spine, breathing, and circulation. Treatment of submersion injuries focuses on correcting hypoxia and fluid imbalances, supporting basic physiologic functions, and rewarming when hypothermia is present. Most drowning victims do not aspirate any liquid due to laryngospasm.
In reviewing the chart, which patient assessment is likely to have the greatest impact on this patient's risk of death from the accident? Tab 1 Background ED assessment Current assessment Male Found floating face down after surfing accident CPR done by rescuers Tab2 Sinus tachycardia with frequent premature ventricular contractions (PVCs) Mechanical ventilation Tab3 Left pupil size 10 cm, not reactive to light Pulmonary artery wedge pressure (PAWP)16 mm Hg PaO2 108 mm Hg, FIO2 50%, PEEP 5 cm Cool extremities, weak peripheral pulses a. PAWP 16 mm Hg b. Left pupil 10 cm, not reactive to light c. Sinus tachycardia with frequent PVCs d.Cool extremities, weak peripheral pulses
b. Left pupil 10 cm, not reactive to light Unilateral pupil dilation without response to light can be a clinical indicator of tentorial herniation of the brain and can occur in a surfing accident as the surfboard and patient are forcefully tossed around in the waves. If the excessive intracranial pressure is allowed to continue, the patient is at a high risk for brainstem death. This finding merits emergency interventions to prevent death. The PAWP, sinus tachycardia with frequent PVCs, and cool extremities with weak peripheral pulses do not indicate imminent death