H&C Ch 72 Emergency Nursing

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?

Administer analgesics as ordered

A patient who has been admitted to the intensive care unit (ICU) with extensive burns is conscious but unable to speak due to upper airway trauma. When communicating with this patient, the ICU nurse should adopt which of the following strategies?

Ask the patient questions that can be answered with a nod or a shake of the head. R: Communication strategies for patients who cannot speak include asking yes or no questions to which patients may nod their head. There is no indication that the patient has a deficit in cognition of understanding, so speaking more slowly or loudly than normal is unnecessary. It would be inappropriate to defer to the patient's friend or family member if the patient is conscious.

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.)

Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. R:A history is obtained only if the patient has not already talked to a police officer, social worker, or crisis intervention worker. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient's own words. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings. Each item of clothing is placed in a separate paper bag. The bags are labeled and given to appropriate law enforcement authorities. The patient is examined (from head to toe) for injuries, especially injuries to the head, neck, breasts, thighs, back, and buttocks. The exam focuses on external evidence of trauma (bruises, contusions, lacerations, stab wounds).

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

Brightly colored clothes help to ward off bees

Which solution should the nurse use to replace lost fluids in a client?

Lactated Ringer solution R: Isotonic electrolyte solutions and blood component therapy

Which triage category refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment?

Emergent

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?

Flumazenil R: Lorazepam is a nonbarbiturate sedative whose effects are reversed with flumazenil.

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.

Gunshot wound Stab wound

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?

Heightened anxiety phase R: During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks.

Acetaminophen overdose is treated with administration of which medication?

N-acetylcysteine

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority?

Protecting him or herself R: self safety = priority

A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn?

Rinsing the area with copious amounts of water.

A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound?

Stab R: A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument. A laceration is a tear in the skin with irregular edges and vein bridging. An avulsion is manifested as a tearing away of tissue from the supporting structures. A patterned wound takes on the outline of the object causing the wound.

A client presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the client has an injury to the pancreas. Which laboratory study is used to detect pancreatic injury?

Serum amylase

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?

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

What is a common source of airway obstruction in an unconscious client?

The tongue.

Which of the following statements would most lead a nurse to suspect that a patient is experiencing food poisoning?

"My bro got sick like me after eating the same food."

The nurse is caring for a client in the ED following a sexual assault. The client is hysterical and crying. The client states, "I know I'm pregnant now, maybe I have HIV. Why did this happen to me?" Which is the best response by the nurse?

"Lets talk about this. Want me to call a support person?" R: Support and caring are crucial

A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process?

Attach a cardiac monitor R: Continuous electrocardiograph (ECG) monitoring is performed during the rewarming process because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation

A triage nurse determines that a client with non-life-threatening injuries requires imaging studies and moderate sedation. The triage nurse would document this client as which of the following?

Urgent Clients who have non-life-threatening conditions but require two or more resouces to provide their care would be classified as urgent.