Acute Care - Chapter 72
Permanent brain injury or death will occur within which timeframe secondary to hypoxia?
3 to 5 minutes
A 40-year-old female patient is admitted to the ED with facial bruises and a broken right wrist. Upon further assessment, the nurse notes multiple bruises in various stages of healing. Which of the following is the nurse's best course of action?
Asking the patient if someone is abusing her
A patient presents to the ED after an unsuccessful suicide attempt. The patient is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which of the following medications?
N-acetylcysteine (Mucomyst)
A patient presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the patient into which of the following categories?
Urgent
Which category of triage encompasses patients with serious health problems that are not immediately life threatening?
Urgent
An 85-year-old patient is admitted to the ED. Heat stroke is suspected. The patient's core temperature is 106.2°F (41.2°C), blood pressure (BP) 90/60 mm Hg, and pulse 102 bpm. The nurse understands that the primary treatment measure for the patient will include which of the following?
Immersion of the patient in a cold-water bath
A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway?
Jaw-thrust
After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position?
Approximately at the patient's lips
The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued?
4%
A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate?
• Patient with laryngeal edema secondary to anaphylaxis • Patient with extensive facial trauma • Patient with an obstructed larynx Cricothyroidotomy is used in emergencies when endotracheal intubation is either not possible or contraindicated. Examples include airway obstruction from extensive maxillofacial trauma, cervical spine injury, laryngospasm, laryngeal edema after an allergic reaction or extubation, hemorrhage into neck tissue, and obstruction of the larynx.
A patient with a history of major depressive disorder is brought to the emergency department by a friend, who reports that the patient took an overdose of prescribed amitriptyline. Which of the following findings would the nurse expect to assess?
• Tachycardia • Visual hallucinations • Clonus Amitriptyline is a tricyclic antidepressant. In cases of overdose, the patient would likely experience tachycardia, hypotension, confusion, visual hallucinations, clonus, tremors, hyperactive reflexes, seizures, blurred vision, flushing, and hyperthermia.
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?
Stage III Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis
When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate?
Positioning the hands in the midline slightly above the umbilicus
As part of an emergency department team, an emergency nurse is conducting a secondary survey on a client. Which of the following would the nurse include?
Applying electrocardiogram electrodes
A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding?
Delayed capillary refill
A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke?
Delirium Manifestations of heat stroke include a temperature of 105 degrees F or greater (40.5 degrees C or greater), anhidrosis (absence of sweating), central nervous system dysfunction (bizarre behavior, delirium, confusion, or coma), hot, dry skin, tachycardia, tachypnea, and hypotension.
The nurse is conducting a secondary survey on a patient in the ED. Which of the following is completed during the secondary survey?
Diagnostic and laboratory testing
A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following?
Diving in an ocean
Which of the following statements reflects the nursing management of the patient with a white phosphorus chemical burn?
Do not apply water to the burn Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or deepening of the burn.
Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment?
Emergent
A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse?
Ensure a patent airway and that the patient is receiving 100% oxygen.
For a patient who is experiencing multiple injuries, which sequence of medical or nursing management would the nurse identify as a priority?
Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries.
A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test?
Evidence of feces A diagnostic peritoneal lavage is considered positive if there is bile, feces, or food in the specimen, a red blood cell count greater than 100,000/mm3, and a white blood cell count greater than 500/mm3
Which triage category would a patient that requires simple first aid or basic primary care?
Fast track Fast track patients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician's office. Urgent patients have serious health problems that are not immediately life threatening. They must be seen within 1 hour. Emergent patients have the highest priority, their conditions are life threatening and they must be seen immediately. Nonurgent patients have episodic illness that can be addressed within 24 hours without increased morbidity
A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse?
Have the patient lie down and place the arm below the level of the heart. Initial first aid at the site of the snakebite includes having the person lie down, removing constrictive items such as rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Airway, breathing, and circulation are the priorities of care.
The nurse is caring for a victim of a sexual assault. The patient is fearful and experiencing flashbacks. The nurse recognizes that the patient is experiencing which of the following phases of the psychological reaction to rape?
Heightened anxiety phase
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?
High-pitched noise on inhalation
A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock?
Hypovolemia
Which of the following solutions should the nurse anticipate for fluid replacement in the male patient?
Lactated Ringer's solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.
A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate?
Massaging the feet
The nurse is administering antivenin to a patient who was bitten on the arm by a poisonous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after?
Measure the circumference of the arm.
A patient with intra-abdominal injuries is brought to the emergency department. Which of the following would most likely alert the nurse to suspect internal bleeding secondary to a ruptured spleen?
Pain in the left shoulder
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 himself or herself
A nurse is establishing a patient's airway. Which action would the nurse perform first?
Repositioning the patient's head
Which of the following guidelines is appropriate to helping family members cope with sudden death?
Show acceptance of the body by touching it, giving the family permission to touch
An adolescent is brought to the ED after a vehicular accident and is pronounced dead on arrival (DOA). When the parents arrive at the hospital, what is the priority action by the nurse?
Speak to both parents together and encourage them to support each other and express their emotions freely.
A nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?
Supporting the client's emotional status
A patient present to the ED following a work-related injury to the left hand. The patient has an avulsion of the left ring finger. Which of the following correctly describes an avulsion?
Tearing away of tissue from supporting structures
A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following?
Xiphoid process
A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do?
• Ask the family if they would like to view the body. • Provide a private place for the family to be together. • Allow the family to express their emotions freely
A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following?
• Cool, moist skin • Increasing heart rate • Delayed capillary refill • Decreasing blood pressure
Nursing students are reviewing information about anaphylactic reactions and their possible causes. The students demonstrate understanding of this information when they identify which of the following as a common cause?
• Insect stings • Medications • Latex • Eggs • Shellfish
