Exam 6: Medical Emergencies

A tornado strikes a community, resulting in multiple trauma victims. What is the most appropriate action of the nurse working in an acute care unit of the receiving facility in implementing the disaster preparedness plan?

Follow the formal written plan of action for coordinating the response of the hospital staff. When a disaster occurs, a formal written plan of action is put into place. All nurses will follow the formal plan of action. Nurses will be notified via telephone if not on duty and will be asked to come in. Those working in the hospital will be sent to the various designated areas within the hospital to care for clients who will be brought in. This plan needs to identify how areas will be used so there is not indecision at the time of the disaster. These are important components of a disaster preparedness plan. A formal fan-out contact list would be in place. Nurses need to commit to the disaster, not just have a volunteer plan. The disaster plan will focus on having health professionals and supplies available.

The nurse is preparing to administer thiothixene to a client with schizophrenia and assesses muscle rigidity, a temperature of 103°F (39.4°C), an elevated serum creatinine phosphokinase level, stupor, and urinary incontinence. Which is the priority action by the nurse?

Hold the medication and notify the health care provider. The client demonstrates all the classic signs of neuroleptic malignant syndrome (NMS). The medication should not be administered, and the provider should immediately be notified. This can be a fatal reaction to the antipsychotic medication. Any of the antipsychotic medications can cause NMS, which is treated by stopping the medication. The client's ability to tolerate other antipsychotic medications after NMS varies, but the use of another antipsychotic appears possible in most instances. Diphenhydramine and benztropine are administered for the treatment of dystonia but will not be effective for NMS.

Common results of acute respiratory failure are hypoxemia and:

Hypercapnia The common result of respiratory failure is hypoxemia, or low level of oxygen in the blood, and hypercapnia, or excess carbon dioxide in the blood. Acute hypoxia incites sympathetic nervous system responses such as tachycardia. Hypercapnia refers to an increase in carbon dioxide levels. The manifestations of hypercapnia consist of those associated with the vasodilation of blood vessels, including those in the brain and depression of the central nervous system (e.g., carbon dioxide narcosis). Thrombus formation in pulmonary vessels is unrelated to ventilation failure.

A client receiving thyroid replacement therapy develops influenza and forgets to take the prescribed thyroid replacement medicine. The nurse understands that skipping this medication puts the client at risk for developing what life-threatening complication?

myxedema coma Myxedema coma (severe hypothyroidism) is a life-threatening condition that may develop if thyroid replacement medication isn't taken. Although thyroid storm is life-threatening, it is caused by severe hyperthyroidism. Systolic hypertension is associated with thyroid storm. A cerebrovascular accident is not typically associated with hypothyroidism.

A nurse is caring for a client after an open lung biopsy. Which assessment finding requires immediate intervention?

respiratory rate of 44 breaths/minute A respiratory rate of 44 breaths/minute is significant and requires immediate intervention. The client may be experiencing postoperative complications, such as pneumothorax or bleeding. An oxygen saturation level of 96% on 3 L of oxygen and a pain level of 4 out of 10 may be expected after an open biopsy. While a temperature of 38.1°C (100.5°F) is a concern, it does not require immediate intervention.

The nurse enters a client's room and finds the client slumped over in a chair. What actions would the nurse take? Place the steps in the correct order from first to last. All options must be used.

Establish unresponsiveness. Confirm there are no respirations. Call for the resuscitation team. Place the client on a firm surface. Deliver 30 chest compressions at a rate of 100 per minute. Have a second person deliver 2 rescue breaths for each 30 compressions. According to American Red Cross, the nurse should first establish unresponsiveness. After unresponsiveness is confirmed, the nurse should confirm there are no respirations. If the client is not breathing, the nurse activates the resuscitation team. Next, the nurse places the client on a firm surface. If there is no pulse, the nurse begins cycles of 30 compressions and 2 breaths, ideally with a second person using a bag-valve mask to deliver the breaths. The rate of compressions should be about 100 per minute.

A 12-year-old client arrives at the emergency room experiencing nausea, vomiting, headache, and seizures. The client is diagnosed with bacterial meningitis. Other findings include a decrease in urine production, hyponatremia, and water intoxication. Which pituitary gland disorder is most associated with these symptoms?

syndrome of inappropriate antidiuretic hormone (SIADH) Syndrome of inappropriate antidiuretic hormone (SIADH) is a rare condition in which there is overproduction of antidiuretic hormone by the posterior pituitary gland. This results in a decrease in urine production and water intoxication. As sodium levels fall in proportion to water, the child develops hyponatremia or a lowered sodium plasma level. It can be caused by central nervous system infections such as bacterial meningitis. As the hyponatremia grows more severe, coma or seizures occur from brain edema. Diabetes insipidus is characterized by polyuria, not decreased urine production. Hyposecretion of somatotropin (growth hormone) results in undergrowth; hypersecretion results in overgrowth.

A client who sustained a complete C6 spinal cord injury 6 months ago has been admitted to the hospital for pneumonia. The nurse observes the client with diaphoresis above the level of C6 and the blood pressure is 260/140 mm Hg. What is the first intervention the nurse should provide?

Elevate the head of the bed. Autonomic dysreflexia is a clinical emergency, and without prompt and adequate treatment, convulsions, loss of consciousness, and even death can occur. The major components of treatment include monitoring blood pressure while removing or correcting the initiating cause or stimulus. The person should be placed in an upright position, and all support hose or binders should be removed to promote venous pooling of blood and reduce venous return.

A client with third-degree burns over 40% of his body is best cared for in which type of health care environment?

Hospital admission and referral to burn center Minor burns are managed on an outpatient basis. Moderate burns involve a hospital admission. Major burns in involve hospital admission with a referral to a burn center if available.

A nursing assessment of a client who has been diagnosed with neuroleptic malignant syndrome (NMS) would most likely reveal which signs?

Hyperpyrexia, severe hypertension, and diaphoresis Fever, hypertension, and diaphoresis are cardinal symptoms of NMS and should be immediately addressed.

An infant with craniosynostosis from Apert syndrome becomes lethargic and starts to vomit. What is the priority nursing intervention?

Notify the doctor and prepare for surgery. The child is exhibiting signs and symptoms of increased intracranial pressure related to premature fusing of the skull joints. Surgery will be needed to relieve the pressure. IV dextrose is contraindicated with increased intracranial pressure. Waiting 1 hour to reassess may lead to brain damage and death. Monitoring intake and output is needed with a hospitalized child but is not the priority intervention based on presentation of symptoms.

A nurse has just learned that her child has a life-threatening complement disorder known as hereditary angioneurotic edema (HAE). Due to deficiency in C1-INH, the nurse needs to be prepared for which possible life-threatening clinical manifestation?

Swelling of the airway HAE is a rare, life-threatening complement disorder that results from deficiency of C1-inhibitor (HAE-C1-INH). It is an inherited autosomal dominant trait that causes mutation in the 11th chromosome. Deficiencies in C1-INH result in uncontrolled release of vasoactive substances that promote vascular permeability. The net result is development of tissue swelling in the subcutaneous tissues of the extremities, face/torso, or upper airway and GI tract. Laryngeal edema is a life-threatening manifestation that can lead to complete airway obstruction and death without interventions.

The nurse is caring for a client with small cell lung cancer (SCLC) and known mediastinal lymph node involvement. What new assessment finding should the nurse prioritize as evidence the client requires emergent intervention?

Swelling of the neck and face Of the symptoms listed, the swelling of neck and face should be prioritized as signs of superior vena cava syndrome (SVCS), where the tumor bulk impedes the draining of the superior vena cava. This is considered an oncologic emergency if the onset is rapid. Given this is a new finding, the nurse should intervene immediately. A decrease in urine output, increase in peripheral edema, and oxygen saturation under 95% all require further investigation and may lead to urgent intervention, but the evidence of SCVS should be prioritized.

When the nurse is caring for a child presenting with a traumatic injury, which action is priority?

Perform a primary assessment The nurse would perform a primary assessment. When assessing a child with a traumatic injury, airway (A), breathing (B), and circulation (C) are assessed first: assess the patency of the airway and establish the effectiveness of breathing, examining the child's respiratory effort, breath sounds, and color; evaluate the circulation, noting pulse rate and quality and observing the color, skin temperature, and perfusion. Once this is accomplished, the nurse would notify the health care provider and apply monitors as needed. The nurse should ensure a code cart is available before the start of the shift.

The nurse is administering a blood transfusion to a client over 4 hours. After 2 hours, the client reports chills and has a fever of 101°F, an increase from a previous temperature of 99.2°F. What does the nurse recognize is occurring with this client?

The client is having a febrile nonhemolytic reaction. The signs and symptoms of a febrile nonhemolytic transfusion reaction are chills (minimal to severe) followed by fever (more than 1°C elevation). The fever typically begins within 2 hours after the transfusion is begun. Although the reaction is not life threatening, the fever, and particularly the chills and muscle stiffness, can be frightening to the client.

A client with a pleural effusion has a diagnostic thoracentesis. The nurse notifies the healthcare provider immediately upon discovering what assessment finding?

asymmetrical chest expansion Of the assessment findings listed, only asymmetrical chest expansion supports the emergent complication of pneumothorax that can occur after a thoracentesis. Other signs and symptoms include tachycardia, pain on inspiration, dyspnea, and a drop in oxygen saturation. Some blood on the dressing after an invasive procedure is not a reason to notify the healthcare provider. A late sign of pneumothorax is hypotension, as the intrathoracic pressure interferes with the return of blood to the heart (decreased preload). An elevated blood pressure is not an emergent finding.

A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:

cover the opening with petroleum gauze. If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress because tension pneumothorax may develop. If tension pneumothorax does develop, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions.

The client calls the health care provider's office stating that her preschooler drank laundry detergent from under the sink. Which statement by the parent needs further instruction?

"I will use syrup of ipecac to get it out of my child's system." The CDC no longer recommends that the syrup of ipecac be used in the home for treatment of poisoning and, furthermore, recommends that it be disposed of safely. All the other statements are accurate. Depending on the amount of detergent ingested, the parent is instructed to first terminate any exposure and then possibly transport the child to a health care facility.

A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which intervention should the nurse take initially?

Institute droplet precautions in addition to standard precautions. Bacterial meningitis is a medical emergency. The child must be placed on droplet precautions until 24 hours of antibiotics have been given. Encouraging the mother to hold and comfort the child is an intervention but not the priority one; the focus is to get the infant the appropriate medications to fight the infection and to prevent its spread. Educating the family about preventing bacterial meningitis would be appropriate later once the initial infection has been controlled. Palpating the fontanels (fontanelles) is used to assess for hydrocephalus.

A nurse has been assigned to assess a pregnant client for placental abruption (abruptio placentae). For which classic manifestation of this condition should the nurse assess?

"knife-like" abdominal pain with vaginal bleeding The classic manifestations of abruption placenta are painful dark red vaginal bleeding, "knife-like" abdominal pain, uterine tenderness, contractions, and decreased fetal movement. Painless bright red vaginal bleeding is the clinical manifestation of placenta previa. Generalized vasospasm is the clinical manifestation of preeclampsia and not of abruptio placentae.

A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy?

100 units of regular insulin in normal saline solution Continuous insulin infusions use only short-acting regular insulin. Insulin is added to normal saline solution and administered until the client's blood glucose level falls. Further along in the therapy, a dextrose solution is administered to prevent hypoglycemia.

The nurse witnesses a client go into cardiac arrest. If the nurse delays intervention, when will the death of brain cells begin?

4-6 minutes Unconsciousness occurs almost simultaneously with cardiac arrest, and the death of brain cells begins within 4 to 6 minutes. Interruption of blood flow also leads to the accumulation of metabolic byproducts that are toxic to neural tissue.

A client reports sudden, acute left eye pain with blurred vision and a headache on the affected side. The client is most likely experiencing:

Acute angle-closure glaucoma The sudden onset of eye pain, blurred vision, and a headache on the affected side indicate acute angle-closure glaucoma, which is an ophthalmic emergency. Subacute angle-closure glaucoma manifests as recurrent short episodes of unilateral pain, conjunctival redness, and blurring of vision associated with halos around lights. Open-angle glaucoma is usually asymptomatic and chronic.

The child presents to the emergency department via ambulance in uncompensated SVT at a rate of 262 beats per minute. The nurse receives an order to administer adenosine IV. In addition to adenosine, what would the nurse bring to the bedside in preparation to administer the adenosine?

a generous saline flush to follow the IV medication Adenosine IV is given rapidly (over 1 or 2 seconds) and is followed by a generous saline flush followed by a rapid (to ensure the medication has entered the vessel). The nurse would assess the child's blood pressure but not specifically in relation to the administration of adenosine. The parents would not sign a consent form for this medication. Vomiting is not a side effect of adenosine.

Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client?

amniotic fluid embolism With amniotic fluid embolism, symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension.

A hospitalized client is found to be comatose and hypoglycemic with a blood sugar of 50 mg/dL. Which of the following would the nurse do first?

Administer 50% glucose intravenously. The unconscious, hypoglycemic client needs immediate treatment with IV glucose. If the client does not respond quickly and the blood glucose level continues to be low, glucagon, a hormone that stimulates the liver to release glycogen, or 20 to 50 mL of 50% glucose is prescribed for IV administration. A dose of 1,000 mL D5W over a 12-hour period indicates a lower strength of glucose and a slow administration rate. Checking the client's urine for the presence of sugar and acetone is incorrect because a blood sample is easier to collect and the blood test is more specific and reliable. An unconscious client cannot be given a drink. In such a case glucose gel may be applied in the buccal cavity of the mouth.

Which condition is treated with an adrenergic agonist?

Anaphylaxis Epinephrine, a prototype adrenergic agonist, is used to relieve the acute bronchospasm and laryngeal edema of anaphylactic shock. Since adrenergic agonists act as cardiac stimulants, some versions may be used to treat severe bradycardia or hypotension.

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?

Basilar Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).

A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client?

Blood glucose level 1,100 mg/dl HHNS occurs most frequently in older clients. It can occur in clients with either type 1 or type 2 diabetes mellitus but occurs most commonly in those with type 2. The blood glucose level rises to above 600 mg/dl in response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of the excess glucose by producing urine. Initially, the client produces large quantities of urine. If fluid intake isn't increased at this time, the client becomes dehydrated, causing BUN levels to rise. Arterial pH and plasma bicarbonate levels typically remain within normal limits.

A 6-hour-old newborn develops a critical respiratory problem and is rushed to the ICU. The ICU nurses suspect the infant has respiratory distress syndrome (RDS) based on which findings? Select all that apply.

Bluish discoloration of the skin and mucous membranes (central cyanosis) Substernal retractions with each breath Expiratory grunting Infants with RDS present with multiple signs of respiratory distress, usually within the first 24 hours of birth. Central cyanosis is a prominent sign. Breathing becomes more difficult, and retractions occur as the infant's soft chest wall is pulled in as the diaphragm descends. Grunting sounds accompany expiration. Periorbital edema is usually associated with kidney disease in infants. Clubbed fingers occur over a long period of time (years) in clients with COPD.

The nurse is working in the emergency department with a client after endotracheal intubation. The nurse must verify tube placement and secure the tube. List in order the steps that are required to perform this function. All options must be used.

Check end-tidal carbon dioxide levels. Auscultate the chest during assisted ventilation. Confirm that breath sounds are equal bilaterally. Secure the tube in place. Obtain an order for a chest x-ray to document tube placement. Checking end-tidal carbon dioxide levels is the most accurate way of immediately verifying placement. 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 can be performed after these assessments are performed. Finally, an x-ray study will verify and document the correct placement of the tube.

Which diagnosis places a child at the greatest risk for airway obstruction?

Epiglottitis The child with epiglottitis is at risk for airway obstruction. Epiglottitis is a life-threatening supraglottic infection that may cause airway obstruction and asphyxia. The child with bronchiolitis is at risk for respiratory failure resulting from impaired gas exchange. Acute bronchiolitis is a viral infection of the lower airways, most commonly caused by the respiratory syncytial virus (RSV). The symptoms of croup usually subside when the child is exposed to moist air.

The parents of a preschool child are distraught as they carry their limp child into the emergency room. The parents report the child fell approximately 10 feet from a large slide and hit his head "hard enough to knock him out." What is the nurse's next action?

Perform a jaw-thrust technique to assess the patency of the airway. The nurse would first evaluate the airway, assessing its patency. Position the airway in a manner that promotes good air flow. Since cervical spine injury is a possibility, do not use the head tilt-chin lift maneuver; use only the jaw-thrust technique for opening the airway. The description of the injury would be suspicious for cervical injury. The nurse would evaluate the child's airway before evaluating pain scale and managing cervical concerns, although the nurse is managing cervical concerns by not performing a head tilt-child lift maneuver. A pulse oximeter measurement would not be the priority.

The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team?

Sudden shortness of breath Sudden shortness of breath can be a sign of amniotic fluid embolism and requires emergent intervention. This can occur suddenly during labor or immediately after. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension. It must be reported to the care team so proper interventions may be taken. Other symptoms can include hypotension, cyanosis, hypoxemia, uterine atony, seizures, tachycardia, coagulation failure, DIC, and pulmonary edema.

A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate?

fetal distress related to hypoxia When meconium is present in the amniotic fluid, it typically indicates fetal distress related to hypoxia. Meconium stains the fluid yellow to greenish brown, depending on the amount present. A decreased amount of amniotic fluid reduces the cushioning effect, thereby making cord compression a possibility. A foul odor of amniotic fluid indicates infection. Meconium in the amniotic fluid does not indicate CNS involvement.

Which situation would be most deserving of a pediatrician's attention?

A midwife notes that a newborn infant's chest is retracting on inspiration and that the child is grunting. Retraction and grunting indicate a significant increase in the work of breathing that can be indicative of respiratory distress syndrome, a situation that would require medical intervention. Periods of hyperventilation interspersed with reduced breathing rates are common during the transition to postpartum ventilation, and infants are commonly unable to mouth breathe. Nostril flaring could be a sign of dyspnea, but it can also be a compensatory mechanism that the infant uses to increase oxygen intake; this situation would not be considered as serious as an infant who has chest retractions and grunting.

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse?

Assess lung sounds bilaterally. All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment.

The client is brought to the emergency room with opioid overdose. After the initial assessment for central nervous system (CNS) function, what will be the nurse's priority action?

Administer naloxone. The priority action would be to adminsiter naloxone, an opioid antagonist. Naloxone is given as a rescue drug when opioid overdose occurs, often seen with extreme drowsiness, slowed breathing, or loss of consciousness occurs. It reverses respiratory depression, sedation, and hypotension caused by the opioid agent. Administration of naloxone is life-saving. Naloxone reverses opioid toxicity. Because the client has opioid overdose, the priority would be to adminster the antagonist. Questioning about what opioid was used may be important but does not take priority over measures to save the client. The initial set of vital signs is important, but without the naloxone the client could die so frequent vitals would not be the priority. Baseline vitals are taken and then monitored more frequently after administration of naloxone. The nurse must treat the problem at hand, which is the focus of the overdose. Cognition and ability to arouse the client should improve after the administration of the opioid antagonist.

A client admitted with digitalis toxicity has been taking the same dose for more than 20 years. The family asks the nurse how someone can develop a toxic level while taking the usual dose. How would the nurse respond?

Toxicity can occur even on low-dose therapy due to various factors including advanced age Digitalis toxicity is one of the most commonly encountered drug-related reasons for hospitalization because the drug has a narrow therapeutic index and the endpoint of effective therapy is often difficult to define and measure. Toxicity can occur due to many factors, including advanced age, contributing medical conditions, and declining renal function. Nothing in the scenario indicates incorrect formulation, incorrect dosing, or renal impairment.

Which sexually active woman most likely faces the highest risk of developing an ectopic pregnancy?

A 42-year-old who has decided to try to have one more child and has had her tubal ligation reversed Previous tubal ligation is an identified risk factor for ectopic pregnancy. Young age, use of injection contraception, and low BMI are not specifically associated with ectopic pregnancy.

Your hospital has had an influx of clients who are in respiratory distress and require ventilator assistance. What might this indicate?

A bioterrorism attack If large numbers of people were to become acutely ill simultaneously as a consequence of bioterrorism, the numbers of ventilators available in any particular agency would likely become exhausted quickly. This scenario does not indicate a natural disaster. Options B and C are distractors to the question.

A client is brought to the Emergency Department by a family member that found the client unresponsive and "barely breathing." The family member states the client is a heroin addict. Which is the priority action by the nurse?

Administer naloxone immediately. Administration of naloxone (Narcan), an opioid antagonist, is the treatment of choice because it reverses all signs of opioid toxicity. If the medication is not administered immediately, the client will go into respiratory arrest. Taking a detailed history from the clients family member is not important at this time and will delay treatment. It is not a priority to obtain an ECG at this time since the priority is to reverse the effects of the opioid. Methadone is used as a long-term option for rehabilitation and not as a treatment for overdose.

A patient with a history of hypothyroidism is admitted to the intensive care unit unconscious and with a temperature of 95.2ºF. A family member informs the nurse that the patient has not taken thyroid medication in over 2 months. What does the nurse suspect that these findings indicate?

Myxedema coma Myxedema coma is a rare life-threatening condition. It is the decompensated state of severe hypothyroidism in which the patient is hypothermic and unconscious (Ross, 2012a). This condition may develop with undiagnosed hypothyroidism and may be precipitated by infection or other systemic disease or by use of sedatives or opioid analgesic agents. Patients may also experience myxedema coma if they forget to take their thyroid replacement medication.

A client who developed a deep vein thrombosis during a prolonged period of bed rest has deteriorated as the clot has dislodged, resulting in a pulmonary embolism. Which type of shock is this client at risk of experiencing?

Obstructive shock Obstructive shock results from mechanical obstruction of the flow of blood through the central circulation, such as the blockage that characterizes a pulmonary embolism.