MedSurg Quiz 2-Chapters 72, 73

A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication? A. N-acetylcysteine B. Flumazenil C. Naloxone D. Diazepam

A

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 benzodiazipine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient? A. "Are you hearing anything that is disturbing you?" B. "Are you experiencing any burning or numbness?" C. "Are you finding the light is too harsh or bothering your eyes?" D. "Does it feel like there is a tight band around your head?"

A

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? A. "Let's talk about this. Do you want me to call a support person?" B. "Do you want to discuss antipregnancy measures?" C. "Do you want the phone number for the National Sexual Assault Hotline?" D. "Would you like us to complete HIV testing?"

A

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. A. Gunshot wound B. Knife-stab wound C. Motor-vehicle crash D. Fall from a roof E. Being struck with a baseball bat

A, B

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? A. "I should always wear something on my feet when I'm outside." B. "Brightly colored clothes help to ward off bees." C. "If a bee comes near me, I should stay still." D. "I need to avoid using perfumes and scented soaps when I'm going outside."

B

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? A. White blood cell count B. Serum amylase C. Urinalysis D. Hemoglobin and hematocrit

B

Ecchymosis

Confusion-blood trapped under the skin

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? A. The client agrees to attend supportive counseling. B. The client agrees to involve his family in psychotherapy. C. The client agrees to ongoing participation in one or more support groups. D. The client agrees to detoxification, rehabilitation, and participation in an aftercare program.

D

A nurse is establishing a patient's airway. Which action would the nurse perform first? A. Giving abdominal thrusts B. Using the jaw-thrust maneuver C. Inserting an artificial airway D. Repositioning the patient's head

D

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? A. Dilution with water or milk B. Gastric lavage C. Administration of activated charcoal D. Induced vomiting

D

The nurse is caring for an intensive care unit client who has died with family members at the bedside. The death was sudden and unexpected resulting from a car accident that took place three days ago. The family is upset and the client's partner, crying loudly, yells, "How did this happen? We were just about to celebrate his birthday. He can't be gone!" The family member continues to cry inconsolably. How should the nurse respond? A. "I will get you some medication that will help you feel more calm." B. "He has passed on to a better place now." C. "It is important to face the reality that he is gone." D. "We did everything we could possibly do to try to save his life."

D

Laceration

Skin tear with irregular edges

Hematoma

Tumor like mass of blood under skin

Avulsion

Wound where skin tears away from supporting structures

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? A. Heightened anxiety phase B. Acute disorganization phase C. Denial phase D. Reorganization phase

A

Which medication reverses severe respiratory depression and coma? A. Naloxone hydrochloride B. Diazepam C. Flumazenil D. N-acetylcysteine

A

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.) A. Have the patient shower or wash the perineal area before the examination. B. Assess and document any bruises and lacerations. C. Record a history of the event, using the patient's own words. D. 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. E. Ensure that the police are present when the examination is performed.

B, C, D

A nurse is preparing an in-service education program about emergency nursing to a group of newly hired nurses who will be working in the emergency department. When describing the current status of visits to the emergency department, which of the following would the nurse include in the presentation? A. The majority of clients arriving at the emergency department arrive by ambulance. B. Clients with Medicaid use the emergency department more often than clients with private health insurance. C. Heart attacks and stroke account for most of the visits to the emergency department. D. Clients, on average wait about a hour before being seen by a health care provider.

B

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? A. Apply a tourniquet. B. Apply firm pressure over the involved area or artery. C. Elevate the injured part. D. Immobilize the area to control blood loss.

B

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? A. Forceful coughing B. Wheezing between coughs C. High-pitched noise on inhalation D. Refusal to lie flat

C

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? A. Stage I B. Stage II C. Stage III D. Stage IV

C

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? A. Remove the peripheral IV line B. Start a dextrose 5% water infusion C. Run a normal saline line to keep the vein open D. Obtain a blood culture from the IV insertion site

C

What is a common source of airway obstruction in an unconscious client? A. A foreign object B. Saliva or mucus C. The tongue D. Edema

C

Which guideline is appropriate for a nurse to implement while helping family members cope with the sudden death of a loved one? A. Inform the family that the client has passed on. B. Obtain orders for sedation for family members. C. Show acceptance of the body by touching it, giving the family permission to touch. D. Provide details of the factors attendant to the sudden death.

C

Abrasion

Loss of the surface layer of skin