Med Surg 2 Final (Ch's 9-12, 47)

Integrated Process: Nursing Process (Assessment) 2. In what sequence would a client move through the process of admission to disposition in emergency care? (Place in order of priority.) a. Client is transported to the medical-surgical floor. b. Emergency department (ED) nurse gives a report on the client. c. Paramedics arrive and start IV access. d. Nurse and other health care provider(s) perform assessment. e. Emergency medical technicians (EMTs) provide oxygen and vital sign monitoring. f. Laboratory technician obtains blood specimens.

e, c, d, f, b, a When clients are in an emergency situation, EMTs arrive on the scene first. EMTs apply oxygen and obtain vital signs to determine a baseline for further care. EMTs can provide basic life support measures and can assess ABCs. Second on the scene are paramedics. Starting IV access and performing advanced life support is within the paramedic's scope of practice. The client is then transported to an ED, where nurses and other health care providers perform an initial assessment. Laboratory technicians are notified and appropriate blood specimens are obtained for diagnostic testing. When the client is stable, the ED nurse gives report to the medical-surgical unit nurse, and the client is finally transferred to an inpatient room. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Nursing Process (Assessment) COMPLETION 1. The nurse is preparing to administer a prescribed dose of intravenous dexamethasone (Decadron) to a client after craniotomy. The pharmacy supplies dexamethasone 40 mcg in 20 mL normal saline to be administered over 15 minutes. The nurse sets the IV pump at a rate of _____ mL/hr.

80 20 mL/15 min = x mL/60 min 15x = 1200 x = 80 mL/hr DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Dosage Calculation)

Integrated Process: Nursing Process (Assessment) 4. The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client? a. Impaired proprioception b. Aphasia c. Agraphia d. Impaired olfaction

A A stroke to the right cerebral hemisphere causes impaired visual and spatial awareness. The client may present with impaired proprioception and may be disoriented as to time and place. The right cerebral hemisphere does not control speech, smell, or the client's ability to write. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 5. The nurse is teaching a wilderness survival class. Which statement by a participant indicates that additional teaching is needed? a. "If I get too cold, I can have some brandy to help me get warmed up." b. "My climbing partner should let me know right away if my nose turns white." c. "If my partner can't think straight, we should descend to a lower altitude." d. "It is okay to feel a little short of breath when I am climbing, but not at rest."

A Alcohol will increase the risk of cold-related injuries and should be avoided. The other options all show good understanding of the education. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

Integrated Process: Nursing Process (Assessment) 5. The nurse is working with a paramedic who just finished assisting at the scene of a school shooting where several students were killed. Which statement by the nurse is most therapeutic? a. "Would you like to talk about what happened?" b. "Surely the department will give you the day off tomorrow." c. "At least the gunman was taken into custody." d. "Let's just sit here for a while quietly."

A Allowing staff members to ventilate their feelings about the incident can facilitate recovery and effective coping afterward. The other choices do not facilitate open communication because the nurse is not providing the opportunity for the paramedic to talk. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

Integrated Process: Communication and Documentation 14. The emergency department nurse manager is explaining concepts of emergency and disaster preparedness to a group of students. Which statement by the nurse manager is most accurate? a. "An internal disaster is something that occurs inside the health care facility." b. "An external disaster occurs when someone not employed here disrupts our operations." c. "A multi-casualty event involves disasters at several different locations." d. "The Joint Commission requires that we participate in a disaster drill once a year."

A An internal disaster is something that occurs within the health care facility, such as a fire. External disasters, such as a tornado or a hurricane, occur outside the health care facility. A multi-casualty event can be managed with hospital resources. The Joint Commission requires hospitals to participate in two disaster drills a year. DIF: Cognitive Level: Knowledge/Remembering REF: p. 155 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency Response Plan)

Integrated Process: Nursing Process (Implementation) 16. The nurse is caring for a client who had a near-drowning incident in a lake. Which action will the nurse take to monitor for possible complications? a. Assess the client's temperature every 4 hours. b. Check the client's blood glucose level before meals. c. Assess the client's bowel sounds three times daily. d. Check the client's skin for petechiae daily.

A Chemicals, algae, microbes, sand, and mud found in lake water put the client at risk for developing a lung infection. The client's temperature should be assessed every 4 hours. A near-drowning victim will not be at risk for glucose or bowel complications. Assessing for petechiae is not necessary. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)

Integrated Process: Nursing Process (Implementation) 22. The nurse is caring for a client who is disoriented as the result of a stroke. Which action does the nurse implement to help orient this client? a. Ask the family to bring in pictures familiar to the client. b. Turn on the television to a 24-hour news station. c. Maintain a calm and quite environment by minimizing visitors. d. Provide auditory and visual stimulation simultaneously.

A For the client with disorientation, the nurse can request that the family bring in pictures or objects that are familiar to the client. The nurse explains what the object or picture represents in simple terms. These stimuli can be presented several times daily. Visitors can also be familiar stimuli to reorient the client. Too much stimuli and constant stimuli can lead to further confusion. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Implementation) 2. The nurse working at a first aid booth during a summer marathon sees several runners. Which runner should be seen first? A runner who: a. Has fallen several times b. Is fatigued c. Thinks he has the flu d. Has tachypnea

A Hot, dry skin, tachycardia, tachypnea, and hypotension are signs of heat stroke. A marathon runner who has fallen several times may have a thermal injury to the brain, causing loss of coordination. Mental status changes from thermal injury to the brain include confusion, bizarre behavior, seizures, and even coma. The nurse should prioritize the client with potential thermal brain injury over the other clients. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Nursing Process (Analysis) 6. The nurse notes that the left arm of a client who has experienced a brain attack is in a contracted, fixed position. Which complication of this position does the nurse monitor for in this client? a. Shoulder subluxation b. Flaccid hemiparesis c. Pathologic fracture d. Neglect syndrome

A Hypertonia causing contracture or flaccidity can predispose the client to subluxation of the shoulder. Contractures are stiff and immobile—not flaccid. Contractures are not caused by fractures or neglect syndrome. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)

Integrated Process: Nursing Process (Implementation) 7. While on a camping trip, the nurse provides care for a camper who was bitten by a black widow spider. What is the priority action of the nurse? a. Apply ice to the site of the bite. b. Apply a loose tourniquet to the limb. c. Give acetaminophen (Tylenol) for pain. d. Cover the camper with a warm blanket.

A Ice inhibits the action of neurotoxin and should be the first intervention provided to a client bitten by a black widow spider. A tourniquet should not be used because it impairs arterial blood flow. Tylenol and covering the camper do not treat the neurotoxic effect of the black widow spider's bite. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Communication and Documentation 22. A hospital has "stood down" from a mass casualty disaster. The staff have rested and eaten. Which action by the nursing supervisor takes priority? a. Restocking the emergency department (ED) b. Making rounds on each unit to check staffing c. Determining which staff can go home d. Planning a critical incident stress debriefing

A Inventorying and stocking the ED are high-priority actions because the usual flow of emergency clients may not be lessened in the wake of a disaster. Supplies may be low or exhausted, and it would be vital to resupply the area. Rounding on inpatient units, determining the staff who can be relieved, and planning a debriefing are certainly important items, but they do not take priority over getting the ED ready for more clients. DIF: Cognitive Level: Knowledge/Remembering REF: p. 162 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency Response Plan)

Integrated Process: Teaching/Learning 20. The nurse is preparing to administer prescribed mannitol (Osmitrol) to a client with a severe head injury. Which precaution does the nurse take before administering this medication? a. Draw up the medication using a filtered needle. b. Have injectable naloxone (Narcan) prepared and ready at the bedside. c. Prepare to hyperventilate the client before drug administration. d. Discontinue a barbiturate-induced coma before drug administration.

A Mannitol (Osmitrol) must be drawn up using a filtered needle to eliminate microscopic crystals. Narcan does not reverse the effects of mannitol. Hyperventilation does not affect administration of this drug, and clients can be given mannitol while in a barbiturate-induced coma. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration)

Integrated Process: Nursing Process (Implementation) 8. A client presents to the emergency department after prolonged exposure to the cold. The client is shivering, has slurred speech, and is slow to respond to questions. Which treatment will the nurse prepare for this client? a. Dry clothing and warm blankets b. Administration of warmed IV fluids c. Peritoneal lavage with warmed normal saline d. Continuous arteriovenous rewarming

A Mild hypothermia is manifested by shivering, slurred speech, poor muscular coordination, and impaired cognitive abilities. Mild hypothermia may be treated with dry clothing and warm blankets. Rewarming should occur slowly by removing wet clothing and providing dry warm blankets first. Other treatments are secondary and should be used to treat moderate to severe hypothermia. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Planning) 23. A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention by the nurse is most beneficial? a. Offer the family choices as appropriate and possible. b. Call the hospital chaplain to stay with the family. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.

A Offering choices when appropriate and when possible gives some personal control back to individuals. The family may or may not want the assistance of religious personnel; the nurse should assess for this before calling anyone. Visiting procedures should take into account the needs of the family. The family may appreciate privacy, but this is not as helpful as allowing choices when the family is able to make them. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss)

Integrated Process: Nursing Process (Implementation) 18. The nurse is triaging clients in the emergency department (ED). Which is true about the presentation of client symptoms? a. Older adults frequently have symptoms that are vague or less specific. b. Young adults present with nonspecific symptoms for serious illnesses. c. Diagnosing children's symptoms often keeps them in the ED longer. d. Symptoms of confusion always represent neurologic disorders.

A Older adults present with symptoms that often are different or less specific than those of younger adults. For example, increasing weakness, fatigue, and confusion may be the only admission concerns. These vague symptoms can be caused by serious illness, such as an acute myocardial infarction (MI), urinary tract infection, or pneumonia. Diagnosing older adults often keeps them in the ED for extended periods of time. DIF: Cognitive Level: Knowledge/Remembering REF: p. 126 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Caring 15. The health care provider suggests inpatient hospice for a client. The family members are concerned that their loved one will receive only custodial care. What is the nurse's best response? a. "The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left." b. "Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop." c. "A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given." d. "Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility."

A Palliative care provides an increased level of personal care designed to manage symptom distress. The focus is on pain control and helping the relative die with dignity. DIF: Cognitive Level: Comprehension/Understanding REF: p. 110 TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Nursing Process (Planning) 12. The nurse is teaching a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? a. "I can go swimming all by myself because I am a certified lifeguard." b. "I cannot leave my toddler alone in the bathtub for even a minute." c. "I will appoint one adult to supervise the pool at all times during a party." d. "I will make sure that there is a phone near my pool in case of an emergency."

A People should never swim alone, regardless of lifeguard status. The other statements indicate good understanding of the teaching. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention)

Integrated Process: Teaching/Learning 12. The hospital administration has arranged for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. "You are free to express your feelings; whatever is said here stays here." b. "Let's determine what we can do better the next time we have this situation." c. "This session is only for nursing and medical staff, not for ancillary personnel." d. "Let's pass around the written policy compliance form for everyone."

A Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services. DIF: Cognitive Level: Comprehension/Understanding REF: p. 162 TOP: Client Needs Category: Psychosocial Integrity (Stress Management)

Integrated Process: Nursing Process (Assessment) 9. A client has been injured in a stabbing incident. Assessment reveals the following: Blood pressure: 80/60 mm Hg Heart rate: 140 beats/min Respiratory rate: 35 breaths/min Bleeding from stabbing wound site Client is lethargic Based on these assessment data, to which trauma center should the nurse ensure transport of the client? a. Level I b. Level II c. Level III d. Level IV

A The Level I trauma center is able to provide a full continuum of care for all client areas. Level II can provide care to most injured clients, but given the extent of his injuries, a Level I center would be better if it is available. Both Levels III and IV can stabilize major injuries, but transport to a higher-level center is preferred, when possible. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)

Integrated Process: Teaching/Learning 19. A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse's interests? a. The Medical Reserve Corps b. The National Guard c. The Health Department d. A Disaster Medical Assistance Team

A The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search and rescue operations and law enforcement. The Health Department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services. DIF: Cognitive Level: Knowledge/Remembering REF: p. 159 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency Response Plan)

Integrated Process: Nursing Process (Planning) 8. An accident has occurred near the hospital, and a victim is brought to the emergency department with severe chest pain, a pulse of 120 beats/min, blood pressure of 100/60 mm Hg, and a respiratory rate of 28 breaths/min. The nurse assesses shortness of breath and diaphoresis. Which color tag does the nurse use when triaging this client? a. Red b. Yellow c. Green d. Black

A The client in the emergent triage category has a condition that may post an immediate threat to life or limb and is given the highest priority. Clients who should be treated emergently receive a red tag. Yellow tags signify major but stable injuries that can wait 30 minutes to 2 hours for definitive care. Green tags designate "walking wounded" who can wait longer than 2 hours to receive care. Black tags are used to designate those who are dead or who are expected to die. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Nursing Process (Planning) 9. The emergency department nurse assesses a middle-aged mountain climber who reports headache, nausea, vomiting, and "feeling winded." What is the nurse's priority intervention? a. Administer acetazolamide (Diamox). b. Administer prochlorperazine (Compazine). c. Perform a neurologic assessment. d. Assess for bowel sounds.

A The client is exhibiting signs of mountain sickness. Acetazolamide (Diamox, Apo-Acetazolamide) is used to prevent and treat acute mountain sickness. The other interventions will not treat mountain sickness. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Nursing Process (Analysis) 10. A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago is brought to the intensive care unit. Which prescribed medication does the nurse prepare to administer? a. Tissue plasminogen activator b. Heparin sodium c. Gabapentin (Neurontin) d. Warfarin (Coumadin)

A The client who has had a thrombotic stroke has a 3-hour time frame from the onset of symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral artery occlusion and re-establish blood flow. Clients must meet eligibility criteria for administration of this therapy. The other medications do not assist in the re-establishment of blood flow for a client with a confirmed thrombotic stroke. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Nursing Process (Implementation) 13. A client has experienced a stroke resulting in damage to Wernicke's area. Which clinical manifestation does the nurse monitor for? a. Inability to comprehend spoken words b. Communication with rote speech only c. Slurred speech d. Inability to make sounds

A The client with damage to Wernicke's area cannot understand spoken or written words. If the client speaks, the language is meaningless, with the client using made-up words. Damage to Wernicke's area does not cause slurred speech, nor will the client communicate with habitual speech only. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Sensory/Perceptual Alterations)

Integrated Process: Caring 16. A new nurse is orienting to the emergency department (ED). Which statement made by the nurse would indicate the need for further education by the preceptor? a. "The emergency medicine physician coordinates care with all levels of the emergency health care team." b. "Emergency departments have specialized teams that deal with high-risk populations of patients." c. "Many older adults seek emergency services when they are ill because they do not want to bother their primary health care provider." d. "Emergency departments are responsible for public health surveillance and emergency disaster preparedness."

A The emergency nurse is one member of the large interdisciplinary team that provides care for clients in the ED. A collaborative team approach to emergency care is considered a standard of practice. In this setting, the nurse coordinates care with all levels of health care team providers, from prehospital emergency medical services (EMS) personnel to physicians, hospital technicians, and professional and ancillary staff. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team)

Integrated Process: Nursing Process (Assessment) 10. The emergency medical technicians (EMTs) arrive at the emergency department with an unresponsive client with an oxygen mask in place. What will the nurse do first? a. Assess that the client is breathing adequately b. Insert a large-bore intravenous line c. Place the client on a cardiac monitor d. Assess for best neurologic response

A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he may not be breathing, or he may be breathing inadequately with the device in place. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Nursing Process (Planning) 16. A nursing administrator is evaluating the hospital's response to a recent internal disaster. The administrator assesses that goals for disaster planning have been met when which outcome is assessed? a. The hospital was able to maintain client, staff, and visitor safety during the disaster. b. Supplies were readily available and were transported rapidly where needed. c. The hospital incident command officer successfully utilized ancillary areas for client care. d. All employees followed the chain of command and established policies and procedures.

A The most important outcome of any internal disaster is maintenance of safety for the hospital's clients, staff, and visitors. Other outcomes listed would be part of a successful disaster response, but are all too narrow to meet this objective. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency Response Plan)

Integrated Process: Nursing Process (Implementation) 11. The nurse is teaching nursing students about personal emergency preparedness. Which statement by a student indicates that further teaching is indicated? a. "I will get a prescription for antibiotics just in case I have to work in an area that has been infected with anthrax." b. "I should keep an extra uniform in my locker in case I get stuck at work." c. "I may be torn between caring for my young daughter and caring for victims at work." d. "I should make plans for my family to evacuate our house in case of tornado or earthquake."

A The student would have no reason to obtain a prescription for anthrax unless he or she demonstrates clinical evidence of anthrax infection or has been exposed to a substance that tests positive for anthrax. Statements about planning to keep an extra uniform at work, recognizing the moral dilemmas he or she might encounter when working in a disaster situation, and understanding personal preparation for disasters all indicate that the student comprehends information about disaster planning and emergency preparedness. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Emergency Response Plan)

Integrated Process: Nursing Process (Assessment) 2. A client with aphasia presents to the emergency department with a suspected brain attack. Which clinical manifestation leads the nurse to suspect that this client has had a thrombotic stroke? a. Two episodes of speech difficulties in the last month b. Sudden loss of motor coordination c. A grand mal seizure 2 months ago d. Chest pain and nuchal rigidity

A Thrombotic stroke is characterized by a gradual onset of symptoms that often are preceded by transient ischemic attacks (TIAs), causing a focal neurologic dysfunction. Two episodes of speech difficulties would correlate with TIAs. The other manifestations are not related to a thrombotic stroke. DIF: Cognitive Level: Comprehension/Understanding REF: Table 47-1, p. 1006 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 20. A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. What statement by the nursing supervisor best addresses these concerns? a. "Deployed DMAT providers are federal employees, so their licenses are good in all 50 states." b. "The government has a program for quick licensure activation wherever you are deployed." c. "During a time of crisis, licensure issues would not be the government's priority concern." d. "If you are deployed, you will be issued a temporary license in the state in which you are working."

A When deployed, DMAT health care providers are acting as agents of the government, and so are considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue that the government would be concerned with, but no programs for temporary licensure or rapid activation are available. DIF: Cognitive Level: Knowledge/Remembering REF: p. 159 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency Response Plan)

Integrated Process: Nursing Process (Assessment) 12. The wife is concerned because her terminally ill husband does not want to eat. What is the nurse's best response? a. "Let him know that food is available if he wants it, but do not insist that he eat." b. "A feeding tube can be placed in the nose to provide important nutrients." c. "Force him to eat even if he does not feel hungry, or he will die sooner." d. "He is getting all the nutrients he needs through his intravenous catheter."

A When family members understand that the client is not suffering from hunger and is not "starving to death," they may allow the client to determine when, what, or if to eat. Often, as death approaches, metabolic needs decrease and clients do not feel the sensation of hunger. Forcing them to eat frustrates the client and the family. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Nursing Process (Planning) MULTIPLE RESPONSE 1. The emergency department (ED) nurse is preparing to transfer a client to the critical care unit. What information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Allergies b. Vital signs c. Immunizations d. Marital status e. Isolation precautions

A, B, E Hand-off communication should be comprehensive so that the nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the client's situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, transmission-based precautions needed, interventions provided, and response to those interventions. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)

Integrated Process: Nursing Process (Implementation) 4. A hospital is receiving large numbers of casualties from a disaster. Which clients does the supervisor identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Client who had open reduction and internal fixation of a femur fracture 3 days ago b. Client who had a colostomy 4 days ago and whose daughter is a registered nurse c. Client admitted last night with community-acquired pneumonia d. Infant admitted 2 days ago for fever of unknown origin e. Client in the medical decision unit for evaluation of chest pain

A, B The client with the femur fracture could be transferred to a rehabilitation facility and the RN could provide care and teaching to her father. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. Also, the infant has not been in the hospital long enough for cultures to return for a definitive diagnosis. The client in the medical decision unit should be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Emergency Response Plan)

Integrated Process: Nursing Process (Evaluation) MULTIPLE RESPONSE 1. A client is admitted for evaluation of a cerebral tumor. Which clinical manifestations does the nurse assess this client for? a. Hemiplegia b. Aphasia c. Hearing loss d. Behavior changes e. Nystagmus

A, B, D If the tumor affects the cerebral hemispheres, hemiplegia, aphasia, and behavioral changes are common. Hearing loss and nystagmus are found with brainstem lesions. DIF: Cognitive Level: Comprehension/Understanding REF: Chart 47-10, p. 1032 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Caring MULTIPLE RESPONSE 1. The hospice nurse is caring for a dying client and her family members. What nursing interventions are appropriate to use? (Select all that apply.) a. Teach family members about physical signs of impending death. b. Encourage the management of adverse symptoms. c. Assist family members by offering an explanation for their loss. d. Encourage reminiscence by both client and family members. e. Avoid spirituality because the client's and the nurse's beliefs may not be congruent. f. Do not encourage hope for the terminally ill client.

A, B, D The nurse should teach family members about the physical signs of death, because family members often become upset when they see physiologic changes in their loved one. Palliative care includes management of symptoms so that the peaceful death of the client is facilitated. Reminiscence will help both the client and family members cope with the dying process. The nurse is not expected to explain why this is happening to the family's loved one. The nurse can encourage spirituality if the client is agreeable, regardless of whether her religion is the same. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Nursing Process (Assessment) 6. A wing of a hospital is on fire. Which actions by the nurse promote safe evacuation of clients? (Select all that apply.) a. Direct ambulatory clients on where to go to be safe. b. Use ambulatory clients to help push clients in wheelchairs. c. Use oxygen tanks for all clients who are on oxygen. d. Manually ventilate clients who are on ventilators. e. Move bedridden clients in their beds if possible.

A, B, D, E Ambulatory clients can evacuate themselves with direction or could be used to help push wheelchair-bound clients. Clients on ventilators need to be removed from the ventilator and "bagged" until evacuated, then they can be put back on the ventilator if one is available. Bedridden clients should be moved in their beds or on stretchers, or carried if needed. Any client who can breathe without oxygen should have it removed for the evacuation because oxygen is an accelerant. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency Response Plan)

Integrated Process: Communication and Documentation 2. The nurse is discharging an older adult client home from the emergency department (ED) after an acute episode of angina. What should the nurse do to ensure client safety upon discharge? (Select all that apply.) a. Reconcile the client's prescription and over-the-counter medications b. Screen the client for functional and cognitive abilities, as well as risk for falls c. Consult physical therapy to organize for home health services d. Arrange for the client's car keys to be taken to prevent an accident e. Review discharge instructions with the client and a family member

A, B, E Before discharge, the nurse should ensure that the client's prescription and over-the-counter medications are evaluated to determine whether the drug regimen should be continued. Discharge education should be provided to the client and a significant other or family member. To prevent future ED visits, screen older adults per agency policy for functional assessment, cognitive assessment, and risk for falls. Case management should be consulted to organize home health services. The nurse should emphasize safety when driving but cannot organize to take the client's keys away. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)

Integrated Process: Teaching/Learning 3. An emergency department nurse moves to a new city, where heat-related illnesses are common. Which clients should the nurse anticipate as at higher risk for heat-related illness? (Select all that apply.) a. Homeless individuals b. Illicit drug users c. Whites d. Hockey players e. Older adults

A, B, E Some of the most vulnerable, at-risk populations for heat-related illness include older adults; blacks (more than whites); people who work outside, such as construction and agricultural workers (more men than women); homeless people; illicit drug users (especially cocaine users); outdoor athletes (recreational and professional); and members of the military who are stationed in countries with hot climates (e.g., Iraq, Afghanistan). DIF: Cognitive Level: Knowledge/Remembering REF: pp. 136-137 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)

Integrated Process: Nursing Process (Implementation) 2. The triage nurse is assessing a client who has been brought to the emergency department (ED) by emergency medical services (EMS) following a mass casualty incident. Which assessment questions are used to determine the appropriate triage category for the client? (Select all that apply.) a. "Can you wiggle your toes?" b. "Are you having any difficulty breathing?" c. "Are you allergic to any medications?" d. "Does your family know that you are here?" e. "Can you tell me what day it is?" f. "Do you have any abdominal or back pain?"

A, B, E, F The triage nurse should assess for possible spinal cord injury, shortness of breath, abdominal or back pain, and disorientation when the client is brought to the ED. Determining allergies, although important, does not assist in categorizing clients, nor does inquiring about the client's family. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Caring 3. The nurse is admitting a new client to the hospital and needs to determine the plan of care. What criterion is required for the client to make his own medical decisions? (Select all that apply.) a. Can communicate his treatment preferences b. Is able to read and write at an 8th grade level c. Is oriented enough to received information d. Can evaluate and deliberate information e. Has completed an advance directive

A, C, D To have decision-making ability, a person must be able to perform three tasks: receive information (but not necessarily oriented 4); evaluate, deliberate, and mentally manipulate information; and communicate a treatment preference. The client does not have to read or write at a specific level. Education can be provided at the client's level, so that he can make the necessary decisions. The client does not need to complete an advance directive to make his own medical decisions. An advance directive will be necessary if he wants to designate someone to make medical decisions when he is unable to. DIF: Cognitive Level: Knowledge/Remembering REF: p. 107 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advance Directives)

Integrated Process: Nursing Process (Implementation) 3. Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

A, C, D, F Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fracture and the client with the head injury would be classified as urgent with red tags. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Nursing Process (Assessment) MULTIPLE RESPONSE 1. The nurse is assessing a group of clients. Which clients are at greater risk for hypothermia or frostbite? (Select all that apply.) a. A young man who has just consumed six martinis b. A young man with a body mass index (BMI) of 42 c. An older man who smokes a pack of cigarettes a day d. A young woman who is anorexic e. An older woman with hypertension f. A young woman who is diabetic

A, C, D, F Clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circulation have a higher incidence of frostbite. DIF: Cognitive Level: Comprehension/Understanding REF: p. 148 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Teaching/Learning 3. Which interventions will be performed during the primary survey for a trauma client? (Select all that apply.) a. Removing wet clothing b. Splinting open fractures c. Initiating IV fluids d. Endotracheal intubation e. Foley catheterization f. Needle decompression g. Laceration repair

A, C, D, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: A, airway and cervical spine control; B, breathing; C, circulation; D, disability; and E, exposure. After completion of primary diagnostic studies and laboratory studies, and insertion of gastric and urinary tubes, the secondary survey, a complete head-to-toe assessment, can be carried out. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Nursing Process (Assessment) 2. The nurse is providing health education at a community center. Which instructions should the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.) a. Seek shelter inside a building or vehicle. b. Seek shelter under a tall tree. c. Do not take a bath or shower. d. Turn off the television. e. Remove body piercings. f. Put down golf clubs or gardening tools.

A, C, D, F When you hear thunder, seek shelter in a safe area such as a building or an enclosed vehicle. Electrical equipment such as TVs and stereos should be turned off. Stay away from plumbing and water, and metal objects. Do not stand under an isolated tall tree or a structure such as a flagpole. Body piercings will not increase a person's chances of being struck by lightning. DIF: Cognitive Level: Knowledge/Remembering REF: Chart 11-6, p. 147 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Assessment) 5. The nurse working with survivors of a disaster wants to assess them for post-traumatic stress disorder. For which clients does the nurse perform further assessment before administering the Impact of Event Scale-Revised? (Select all that apply.) a. Older adult survivor with minor injuries b. Woman who lost both her children c. Middle-aged victim with multiple medical problems d. Young adult who had serious orthopedic injuries e. Older adolescent who had a traumatic brain injury

A, E The Impact of Event Scale-Revised tool should not be used with people who have short-term memory loss, so the nurse should assess the older adult survivor and the client with the brain injury for this problem before administering the tool. The other clients do not have medical issues that would preclude use of this tool. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Stress Management)

Integrated Process: Communication and Documentation 7. The emergency department (ED) nurse is caring for the following clients. Which client does the nurse prioritize to see first? a. 22-year-old with a painful and swollen right wrist b. 45-year-old reporting chest pain and diaphoresis c. 60-year-old reporting difficulty swallowing and nausea d. 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F

B A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Caring 11. The nurse is assessing the dying client. Which manifestations of a dying client should the nurse assess to determine whether the client is near death? a. Level of consciousness b. Respiratory rate c. Bowel sounds d. Pain level on a 0 to 10 scale

B All of these assessments should be performed during the dying process. As the peripheral circulation decreases, the client's level of consciousness and bowel sounds decrease. The client is unable to provide a numeric number on a pain scale. The nurse should continue to assess respiratory rate throughout the dying process. As the rate drops significantly and breathing becomes agonal, death is near. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Communication and Documentation 3. A client is receiving follow-up care after surviving a tornado. The client reports insomnia and the nurse notes that the client jumped as the nurse entered the room. Which action by the nurse is most appropriate? a. Document findings on the client's chart and inform the physician. b. Perform additional assessments for post-traumatic stress disorder. c. Educate the client on nonpharmaceutical methods to promote sleep. d. Plan to initiate a referral to a psychologist experienced in survivor issues.

B An individual may experience physical symptoms as a normal response to profound grief or loss, particularly after a traumatic incident. Manifestations such as insomnia, being startled easily, having flashbacks, or feelings of numbness may indicate post-traumatic stress disorder, and the nurse should first assess for this problem. The nurse should document assessment findings, but only after performing a more thorough assessment. A referral may be necessary, but the nurse does not have enough information yet to initiate it. If assessment reveals that methods to assist with sleep would be helpful, the nurse could provide that education. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)

Integrated Process: Communication and Documentation 17. An unresponsive client with poor ventilator effort and a pulse rate of 120 beats/min arrives at the emergency department. What should the nurse do first? a. Place the client on a non-rebreather mask. b. Begin bag-valve-mask ventilation. c. Initiate cardiopulmonary resuscitation. d. Prepare for chest tube insertion.

B Apneic clients and those with poor ventilatory effort need bag-valve-mask (BVM) ventilation for support until endotracheal intubation is performed and a mechanical ventilator is used. A non-rebreather mask would be appropriate only if the client had adequate spontaneous ventilation. Cardiopulmonary resuscitation is necessary only if the client is pulseless. Chest tubes are inserted for decompression and pneumothorax. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Nursing Process (Assessment) 3. The nurse is caring for a client who is considering being admitted to hospice. What is the nurse's best response? a. "Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge." b. "Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms." c. "Hospice care will not help with your symptoms of depression. I will refer you to the facility's counseling services instead." d. "You seem to be experiencing some difficulty with this stage of the grieving process. Let's talk about your feelings."

B As both a philosophy and a system of care, hospice care uses an interdisciplinary approach to assess and address the holistic needs of clients and families to facilitate quality of life and a peaceful death. This holistic approach neither hastens nor postpones death but provides relief of symptoms experienced by the dying client. DIF: Cognitive Level: Comprehension/Understanding REF: p. 108 TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Teaching/Learning 21. A community disaster has occurred and the hospital's emergency department (ED) has efficiently triaged, treated, and transferred most clients to appropriate units. The hospital incident command officer wants to "stand down" from the emergency plan. Which question by the nursing supervisor is most beneficial at this time? a. "Are you sure no more victims are coming into the ED?" b. "Do all other areas of the hospital have the supplies and personnel they need now?" c. "Have all ED staff had the chance to eat and rest recently?" d. "Are all other incident command officers and house supervisors in agreement with you?"

B Before "standing down," the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more "walking wounded" victims may present to the ED; that number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of the facility need that too. Although agreement among incident officers is important, it is not the priority concern before standing down. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency Response Plan)

Integrated Process: Caring 17. A client who is near death appears to be having difficulty breathing. What is the nurse's highest-priority intervention? a. Teach the family how to perform nasotracheal suctioning. b. Request that the physician order morphine sulfate. c. Document the finding in the client's chart. d. Call a respiratory therapist to intubate the client.

B Morphine sulfate is the standard treatment for dyspnea near death; it relieves the psychological and physiologic distress that accompanies breathlessness. Suctioning or intubation may cause the client discomfort. Documentation is important, but it is not the priority intervention because it does nothing to relieve the client's distress. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Caring 8. A terminally ill client has just died in a hospital setting with family members at the bedside. The health care provider is also present. What should be the nurse's priority intervention as postmortem care begins? a. Call for emergency assistance so that resuscitation procedures can begin. b. Ask the family members if they would like to spend time alone with the client. c. Ensure that a death certificate has been completed by the physician. d. Request family members to prepare the client's body for the funeral home.

B Before moving the client's body to the funeral home, the nurse should ask family members if they would like to be alone with the client. Emergency assistance will not be necessary. Although it is important to ensure that a death certificate has been completed before the client is moved to the mortuary, the nurse first should ask family members if they would like to be alone with the client. The client's family should not be expected to prepare the body for the funeral home. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Caring 13. The family members of a client with a terminal illness tell a nurse that the client keeps asking if she is dying. What is the nurse's best response? a. "Whenever she asks about dying, change the subject." b. "Tell her the truth in as gentle a way as possible." c. "Tell her that she will get better eventually." d. "Ask her if she is afraid to die."

B Being honest and truthful at such a time is important. It helps the client develop trust in those caring for her. Changing the subject will frustrate the client and may make her distrustful. Providing false hope is not a realistic intervention. Asking a pointed question often will not elicit the information that you want from the client. It is better to ask open-ended questions. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Teaching/Learning 15. The nurse is planning care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate? a. The facility's neurologist b. The regional poison control center c. The physical therapy department d. A herpetologist (snake specialist)

B Contact the regional poison control center immediately for specific advice on antivenom administration and client management. DIF: Cognitive Level: Knowledge/Remembering REF: p. 141 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team)

Integrated Process: Nursing Process (Analysis) 7. The nurse is caring for a client who has experienced a stroke. Which nursing intervention for nutrition does the nurse implement to prevent complications from cranial nerve IX impairment? a. Turn the client's plate around halfway through the meal. b. Place the client in high Fowler's position. c. Order a clear liquid diet for the client. d. Verbalize the placement of food on the client's plate.

B Cranial nerve IX, the glossopharyngeal nerve, controls the gag reflex. Clients with impairment of this nerve are at great risk for aspiration. The client should be in high Fowler's position and should drink thickened liquids if swallowing difficulties are present. The client would not have vision problems. Turning the plate around would not prevent a complication, nor would limiting the client's diet to clear liquids. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Evaluation) 20. An older client was admitted to hospice owing to impending death in approximately 6 weeks. After 2 months, the family remains at the bedside but is becoming increasingly impatient and irritable. What is the best nursing intervention? a. Ask the family to leave and not return until they are calmer. b. Sit with the family and listen to their concerns and fears. c. Tell the family members not to worry, the client will die soon. d. Consult the chaplain to come and pray with the client's family.

B Death cannot be accurately predicted. The nurse should sit with the family and listen to their concerns. The nurse should not provide false hope or reassurance. Family members should remain with the client as long as they would like. The chaplain should be consulted if the family requests. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

Integrated Process: Nursing Process (Planning) 3. The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. What should the nurse do next? a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the client's spouse to the hospital's crisis team.

B If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Crisis Intervention)

Integrated Process: Nursing Process (Implementation) 25. The nurse is assessing a client who was recently diagnosed with a meningioma. Which statement indicates that the client correctly understands the diagnosis? a. "This is the worst type of brain tumor, and surgery is not an option." b. "My tumor can be removed, but I can still have damage because of pressure in my brain." c. "Even after the surgery, I will need chemotherapy to decrease the spread of the tumor." d. "Radiation is never used on brain tumors because of possible nerve damage."

B Meningiomas arise from the coverings of the brain (the meninges) and are the most common type of benign tumor. This tumor is encapsulated, globular, and well demarcated, and causes compression and displacement of nearby brain tissue. Although complete removal of the tumor is possible, it tends to recur and causes irreversible damage to the brain. The tumor is not treated by chemotherapy or radiation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

Integrated Process: Caring and Communication 7. The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying client's anxiety and restlessness. Which statement by the family member indicates understanding of the nurse's teaching? a. "Maybe we should just hire a round-the-clock sitter to stay with Grandmother." b. "I have some of her favorite hymns on a CD that I could bring for music therapy." c. "I don't think that she'll need pain medication along with her herbal treatments." d. "I will burn therapeutic incense in the room so we can stop the anxiety pills."

B Music therapy is a complementary therapy that may produce relaxation by quieting the mind and removing a client's inner restlessness. Complementary therapies are used in conjunction with traditional therapy. The complementary therapy would not replace pain or anxiety medication but may help decrease the need for these medications. Hiring an around-the-clock sitter does not demonstrate that the client's family understands complementary therapies. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Interventions)

Integrated Process: Nursing Process (Implementation) 13. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. What should the nurse do before providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

Integrated Process: Caring 4. The emergency department nurse is assigned an older adult client who is confused and agitated. Which intervention should the nurse include in the client's plan of care? a. Administer a sedative medication. b. Ask a family member to stay with the client. c. Use restraints to prevent the client from falling. d. Place the client in a wheelchair at the nurses' station.

B Older adults who are confused are at increased risks for falls. Fall prevention includes measures such as siderails up, reorientation, call light in reach, and, in some cases, asking the family member, significant other, or sitter to stay with the client to prevent falls. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention)

Integrated Process: Teaching/Learning 24. The nurse assesses periorbital edema and ecchymosis around both eyes of a client who is 6 hours postoperative for craniotomy. Which intervention does the nurse implement for this client? a. Position the client with the head of the bed flat. b. Apply an ice pack to the affected area. c. Assess arterial blood pressure. d. Notify the health care provider.

B Periorbital edema and ecchymosis are expected after a craniotomy. The nurse should attempt to increase the client's comfort by reducing the swelling with application of ice. The provider does not need to be notified. Lowering the head of the bed and assessing blood pressure will not decrease inflammation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Assessment) 19. The nurse is providing emergency care to a client with frostbite. Which intervention is performed first? a. Wrap the affected area in a warm, dry blanket to rewarm. b. Rewarm the affected area in a 104° F water bath. c. Elevate the affected area above the heart to decrease tissue edema. d. Use a splint to immobilize the affected area.

B Rewarming of the client with frostbite must occur first. Rapid rewarming in a water bath at a temperature of 104° F is preferable. If a warm bath is not available, warm wet towels can be used, but not warm dry blankets. After rewarming the affected area, elevate and apply an immobilization splint. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Nursing Process (Implementation) 8. A client who had a brain attack was admitted to the intensive care unit yesterday. The nurse observes that the client is becoming lethargic and is unable to articulate words when speaking. What does the nurse do next? a. Check the client's blood pressure and apical heart rate. b. Elevate the back rest to 30 degrees and notify the health care provider. c. Place the client in a supine position with a flat back rest, and observe. d. Assess the client's white blood cell count and differential.

B The client is experiencing signs of increased intracranial pressure (ICP). Raising the head of the bed would help decrease ICP. The health care provider should then be notified immediately so that other interventions to reduce ICP can be instituted. Assessing vital signs and white blood cell count is not the priority at this time. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Planning) 5. An emergency department nurse is transferring a client to the medical-surgical unit. What is the most important nursing intervention in this situation? a. Triage the client to determine the urgency of care. b. Clearly communicate client data to the unit nurse. c. Evaluate the need for ongoing medical treatment. d. Perform a thorough assessment of the client.

B The emergency nurse needs to be able to triage, assess, and evaluate. However, these steps have already been carried out in the early phases of the emergency department (ED) admission. When a client is ready to be transferred from the ED, communication with staff nurses from the inpatient units is essential. This report should be a concise but comprehensive report of the client's ED experience. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)

Integrated Process: Nursing Process (Planning) 3. The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting that he is not feeling well. Vital signs are temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priority action of the nurse? a. Encourage drinking of cool water or sports drinks. b. Sponge the victim with cool water and remove his shirt. c. Administer Tylenol (acetaminophen), 650 mg orally. d. Encourage rest, and reassess in 15 minutes.

B The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be transported to the emergency department as quickly as possible. The nurse should take actions to lower his body temperature in the meantime by removing his shirt and sponging his body with cool water. Lowering body temperature by drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The client needs to be cooled quickly and is a priority for treatment. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Teaching/Learning 16. The nurse is caring for a client admitted to the intensive care unit after incurring a basilar skull fracture. Which complication of this injury does the nurse monitor for? a. Aspiration b. Hemorrhage c. Pulmonary embolus d. Myocardial infarction

B This type of fracture may cause hemorrhage from damage to the internal carotid artery. The other problems are not complications of this injury. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Evaluation) 12. The nurse is caring for a client who is immobile from a recent stroke. Which intervention does the nurse implement to prevent complications in this client? a. Position the client with the unaffected side down. b. Apply sequential compression stockings. c. Instruct the client to turn the head from side to side. d. Teach the client to touch and use both sides of the body.

B To avoid complications of immobility, such as deep vein thrombosis, the nurse applies sequential compression stockings or pneumatic compression boots. Efforts are made to mobilize the client as much as possible, and the client should be repositioned frequently. The other interventions will not prevent complications of immobility. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Evaluation) 17. A nursing administrator is reviewing a hospital's disaster planning. The administrator evaluates the plan that addresses which component as being the best? a. Internal disasters such as fires or power outages b. All possible catastrophes in the community c. The Joint Commission's assessment of possible disasters d. Responses to all types of weather-related emergencies

B When The Joint Commission-accredited health care facilities are planning disaster preparedness programs, they need to take an "all-hazards approach" (versus planning by strict guidelines) and to plan for all credible threats to the community that could result in a disaster. This means planning for all events that could conceivably happen in that geographic area, including possible weather events. Planning only for internal disasters is too limited and does not account for weather- or terrorist-related threats. The Joint Commission does not assess what disasters are possible in the areas that accredited hospitals serve. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency Response Plan)

Integrated Process: Caring MULTIPLE RESPONSE 1. A large number of victims arrive at the emergency department after a bus is hit by a train. Which interventions are performed immediately for red-tagged victims? (Select all that apply.) a. Splinting a closed tibial fracture b. Intubating a cyanotic client in respiratory distress c. Initiating IV fluids for a client with a blood pressure of 96/60 mm Hg and a pulse of 144 beats/min d. Attaching an external pacemaker for a client with a heart rate of 44 beats/min e. Performing postmortem care for a client who has just died f. Removing glass that is embedded in a client's arm

B, C, D Priority interventions are those that must be performed to save the client's life, including intubation, IV fluid replacement for shock, and pacemaker placement. Splinting a fracture and removing glass from a client's arm can wait until after life-threatening injuries are cared for. Postmortem care would wait until after all clients have been cared for. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Nursing Process (Assessment) 8. A nurse is triaging clients in the emergency department. Which client complaint would the triage nurse classify as nonurgent? a. Chest pain and diaphoresis b. Decreased breath sounds due to chest trauma c. Left arm fracture with palpable radial pulses d. Sore throat and a temperature of 104° F

C A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration. The client with an arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Nursing Process (Planning) 14. The nurse is triaging clients in the emergency department. Which client should be considered urgent? a. 20-year-old female with a chest stab wound and tachycardia b. 45 year-old homeless man with a skin rash and sore throat c. 75-year-old female with a cough and of temperature of 102° F d. 50-year-old male with new-onset confusion and slurred speech

C A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. Clients with a chest stab wound and tachycardia, and with new-onset confusion and slurred speech, should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Chapter 10: Concepts of Emergency and Trauma Nursing Test Bank MULTIPLE CHOICE 1. While assessing a client in the emergency department, the nurse identifies that the client has been raped. Which health care team member should the nurse collaborate with when planning this client's care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

C All other members of the health care team listed may be used in the management of this client's care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault. DIF: Cognitive Level: Comprehension/Understanding REF: p. 122 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team)

Integrated Process: Caring 4. A hospitalized American Indian client is approaching death. Family members who are standing vigil in the client's room begin to divide up his possessions among themselves as his symptoms progress. What is the nurse's most important intervention? a. Ask the family members to step outside the room so the client cannot hear them. b. Tell the family that they are being insensitive and their behavior is inappropriate. c. Recognize that this is a culturally appropriate activity and document it in the chart. d. Report these activities to the client's physician and the nursing supervisor.

C American Indians often disperse material possessions before or after death to friends and family members. Recognizing this culturally appropriate activity would not be consistent with removing the family, stopping the activity, or reporting the client's family's behaviors. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Cultural Diversity)

Integrated Process: Caring 2. The nurse is discussing advance directives with a client. Which statement by the client indicates good understanding of the purpose of an advance directive? a. "An advance directive will keep my children from selling my home when I'm old." b. "An advance directive will be completed as soon as I'm incapacitated and can't think for myself." c. "An advance directive will specify what I want done when I can no longer make decisions about health care." d. "An advance directive will allow me to keep my money out of the reach of my family."

C An advance directive is a written document prepared by a competent individual that specifies what, if any, extraordinary actions a person would want taken when he or she can no longer make decisions about personal health care. It does not address issues such as the client's residence in his or her own home. DIF: Cognitive Level: Comprehension/Understanding REF: p. 108 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advance Directives)

Integrated Process: Caring 6. The terminally ill client is prescribed morphine to help cope with increasing discomfort. A family member expresses concern that the client is on "too much morphine." What is the nurse's best response? a. "What has the physician told you about your family member's illness?" b. "Don't worry about that. We're following the physician's plan of care." c. "Tell me more about what you mean by too much morphine." d. "You should talk with your physician about this when he makes rounds."

C Asking family members to explain what they mean by "too much morphine" serves to gain more information for the nurse. The other questions will not help the nurse obtain more information about the client's care or the family's concerns. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

Integrated Process: Nursing Process (Intervention) 20. The nurse is caring for a drowning victim after resuscitation. What focused assessment will the nurse perform to identify complications from drowning? a. Palpation of abdominal cavity b. Inspection of skin color c. Auscultation of lungs d. Palpation of pulse strength

C Auscultation of the lungs will assist the nurse to identify complications from drowning, including pulmonary infection and acute respiratory distress syndrome (ARDS). All other assessments are important, but the nurse must focus on the respiratory system as most likely to demonstrate complications. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction in Risk Potential—Potential for Alterations in Body Systems)

Integrated Process: Nursing Process (Assessment) 20. The nurse is caring for a homeless client and consults the emergency department (ED) case manager. What can the ED case manager do for this client? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.

C Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility. DIF: Cognitive Level: Knowledge/Remembering REF: p. 129 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team)

Chapter 47: Care of Critically Ill Patients with Neurologic Problems Test Bank MULTIPLE CHOICE 1. The nurse is obtaining a health history for a client admitted to the hospital after experiencing a brain attack. Which disorder does the nurse identify as a predisposing factor for an embolic stroke? a. Seizures b. Psychotropic drug use c. Atrial fibrillation d. Cerebral aneurysm

C Clients with a history of hypertension, heart disease, atrial fibrillation, diabetes, obesity, and hypercoagulopathy are at risk for embolic stroke. The other disorders are not risk factors for an embolic stroke. DIF: Cognitive Level: Knowledge/Remembering REF: p. 1012 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

Integrated Process: Nursing Process (Implementation) 11. A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse monitor for in this client? a. Repeated syncope b. New-onset confusion c. Spontaneous ecchymosis d. Abdominal distention

C Clopidogrel (Plavix) is an antiplatelet medication that can cause bleeding, bruising, and liver dysfunction. The nurse should be alert for signs of bleeding, such as ecchymosis, bleeding gums, and tarry stools. Plavix does not cause syncope, confusion, or abdominal distention. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions)

Integrated Process: Nursing Process (Implementation) 23. The nurse is planning the discharge of a client who has sustained a moderate head injury and is experiencing personality and behavior changes. The client's wife states, "I am concerned about how different he is. What can I do to help with the transition back to our home?" How does the nurse respond? a. "Be firm and let him know when his behavior is unacceptable." b. "Minimizing the number of visitors will help stabilize his personality." c. "Developing a routine will help provide him with a structured environment." d. "He will return to his normal emotional functioning in 6 to 12 months."

C Developing a home routine that provides structure and repetition is recommended because clients with personality and behavior problems respond best to this type of environment. The client's personality and emotional functioning will never return to normal. The client may be aggressive, and family members must be aware of potential client reactions. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Family Dynamics)

Integrated Process: Nursing Process (Assessment) 19. The emergency department (ED) nurse is assigned to triage clients. What is the purpose of triage? a. Treat clients on a first-come, first-serve basis. b. Identify and treat clients with low acuity first. c. Prioritize clients based on illness severity. d. Determine health needs from a complete assessment.

C ED triage is an organized system for sorting or classifying clients into priority levels, depending on illness or injury severity. The key concept is that clients who present to the ED with the greatest acuity needs receive the quickest evaluation, treatment, and prioritized resource utilization. A person with a lower-acuity problem may wait longer in the ED because the higher-acuity client is moved to the "head of the line." DIF: Cognitive Level: Knowledge/Remembering REF: p. 127 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Nursing Process (Implementation) 9. The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications? a. Administer prescribed analgesics to promote pain relief. b. Cluster nursing procedures together to avoid fatiguing the client. c. Monitor neurologic and vital signs closely to identify early changes in status. d. Position with the head of the bed flat to enhance cerebral perfusion.

C Early detection of neurologic, blood pressure, and heart rhythm changes offers an opportunity to intervene in a timely fashion. Evidence is not yet sufficient to recommend a specific back rest elevation after stroke. Analgesics are often held during the first 72 hours to ensure that the client's neurologic status is not altered by pain medications. Preventing fatigue is not a priority in the first 72 hours. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Planning) 18. A nursing instructor is debriefing students who participated in a community-wide disaster drill. Several students are upset with the black-tagged triage category. Which statement by the nursing instructor is best? a. "To do the greatest good for the greatest number of people, it is necessary to sacrifice some." b. "Not everyone will survive a disaster, so it is best to identify those people early and move on." c. "In a disaster, extensive resources are not used for one person at the expense of many others." d. "With black tags, volunteers can identify those who are dying and can give them comfort care."

C In a disaster, military style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not "sacrificed." Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care. DIF: Cognitive Level: Comprehension/Understanding REF: p. 157 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency Response Plan)

Integrated Process: Caring 14. The client's family members are concerned that the client should have a urinary catheter placed because of her decreasing urinary output. What is the hospice nurse's best response? a. "A Foley catheter is inserted only if she is taking medications that affect output." b. "I will insert a Foley catheter if her urinary output drops below 500 mL/day." c. "A Foley catheter will be inserted if her bladder becomes distended." d. "I will insert a Foley catheter if she becomes incontinent of urine."

C Insertion of an indwelling catheter is acceptable if the client is unable to void, has a distended bladder, and would be more comfortable not moving. The other statements are not appropriate uses for an indwelling catheter in a hospice setting. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Teaching/Learning 13. The nurse is assessing a client recently bitten by a coral snake. Which assessment is the priority? a. Peripheral edema and swelling b. Evaluation of clotting times c. Respiratory rate and depth d. Electrocardiogram rhythm

C Manifestations of coral snake envenomation are the result of its neurotoxic properties. The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse should monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Caring 25. A client has been treated in the emergency department after a tornado and is awaiting discharge instructions. This client is close to losing control, although other family members are attempting to calm him down. Which response by the nurse is most helpful? a. Call security and have them standing by in case they are needed. b. Instruct the person to leave the area until he can calm down. c. Offer the client the choice of waiting in the treatment room or the waiting room. d. Ask the family to help move the client out of the treatment area.

C Offering people choices often is a good way to get them to focus on something other than their distress. Calling security and telling the person to leave might escalate the situation, although if all other methods fail, the safety of staff, clients, and other visitors takes priority. Asking the family to help move the client puts him in a difficult position and may end up causing them injury. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Stress Management)

Integrated Process: Caring 19. An experienced hospice nurse is training a new nurse in the practices of palliative care. What statement by the new nurse indicates understanding about drug therapy for end-of-life care? a. "I can administer as much pain medication as I want because the client is dying." b. "The administration of these medications will hasten the client's death." c. "I can administer medication per the protocol to relieve the client's symptoms." d. "The purpose of palliative sedation is to relieve family members' distress."

C Palliative care nurses follow protocols when administering medications. These protocols are standing prescriptions from the provider that identify the appropriate medication, dose, and situation for administration. The nurse cannot administer more than is prescribed. The medications are given to promote comfort and if administered per protocol will not hasten death. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Teaching/Learning 15. The emergency department (ED) is expecting a large number of casualties after a bridge collapse. Which is a priority consideration for the ED leadership when activating the disaster plan? a. Responding paramedics and rescue personnel will notify the ED about exactly how many victims to expect. b. Responding paramedics and rescue personnel will triage all victims at the bridge collapse site before bringing them to the ED. c. The ED may receive many unexpected victims with minor injuries from the bridge collapse. d. Victims who have been contaminated with gasoline will be decontaminated by rescue personnel before arriving at the ED.

C Paramedics may not note all the "walking wounded" to give the ED an accurate count of victims to expect because these people might evacuate themselves from the accident scene without being seen by paramedics or rescue personnel. They may then secure their own transportation to the hospital and could overwhelm an ED that is already handling many severely injured victims who have been brought in by emergency medical services (EMS). DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency Response Plan)

Integrated Process: Nursing Process (Analysis) 17. A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately? a. Pupil response b. Motor function c. Respiratory status d. Short-term memory

C Respiratory derangements (e.g., hypoxemia, hypercarbia, alterations in pH) can contribute to secondary brain injury in this scenario. Therefore, the important priority is assessment of respiratory status so that secondary brain injury conditions are avoided. The other assessments should be performed after effective respiratory functions have been established. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Assessment) 17. The nurse is working in the emergency department on a hot, humid day, when a hiker is brought in after collapsing. The hiker is confused and tachycardic with a temperature of 105.6° F (40.9° C). Which IV solution and medication will the nurse have ready for the client? a. Normal saline and methylprednisolone (Solu-Medrol) b. Lactated Ringer's solution and morphine sulfate c. Normal saline and lorazepam (Ativan) d. Dextrose 5% and diphenhydramine (Benadryl)

C The client has heat stroke and is at risk for developing seizures, so the nurse should be prepared to administer lorazepam (Ativan) as needed. The optimal solution for clients with heat stroke is IV normal saline. Ringer's lactate solution cannot be used because the liver is unable to metabolize lactate during hyperthermia. Methylprednisolone and diphenhydramine would not be used to treat heat stroke. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Nursing Process (Assessment) 12. The nurse is providing care for a client admitted for suicidal precautions. What priority intervention should the nurse implement first? a. Administer prescribed anti-anxiety drugs. b. Decrease the noise level and the harsh lighting. c. Remove oxygen tubing from the room. d. Set firm behavioral limits.

C The first priority in caring for a mentally ill client is providing a safe environment. This would include removing any item that the client could use to harm himself or herself (or others). All the other interventions can be used in providing a therapeutic environment. However, they are not as imperative as the safety of the client and staff. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention)

Integrated Process: Nursing Process (Analysis) 14. A client who has had a stroke with left-sided hemiparesis has been referred to a rehabilitation center. The client asks, "Why do I need rehabilitation?" How does the nurse respond? a. "Rehabilitation will reverse any physical deficits caused by the stroke." b. "If you do not have rehabilitation, you may never walk again." c. "Rehabilitation will help you function at the highest level possible." d. "Your doctor knows best and has ordered this treatment for you."

C The goal of rehabilitation is to maximize the client's abilities in all aspects of life. The other responses do not answer the client's question appropriately. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

Chapter 11: Care of Patients with Common Environmental Emergencies Test Bank MULTIPLE CHOICE 1. While the nurse is visiting the community pool, an adult swimmer is pulled out of the pool, unconscious and cyanotic. What is the priority action of the nurse? a. Begin chest compressions. b. Move from the pool area. c. Give two rescue breaths. d. Check for a carotid pulse.

C The highest priority is to maintain ventilatory support until the victim can breathe on his or her own. The other options are important, but maintaining the airway and breathing are always priority. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Caring 6. A young man comes into the foyer of the hospital and says that he has a container of anthrax, which he opens and pours on the floor. Which is the priority action for the nurse who first comes upon the scene? a. Don a protective gown, mask, and goggles. b. Escort the man to the decontamination room. c. Begin to evacuate the immediate area. d. Notify the local health department of a biohazard situation.

C The highest priority is to remove people from immediate danger, so the nurse should evacuate the immediate area and prevent injury to those near the spill. Donning personal protective equipment would probably take the nurse away from the scene to obtain the equipment and would not help protect those in immediate danger. The man may need to be escorted to a decontamination area after people are removed from the scene. Reporting the incident to the health department should be done after the scene is secured and could be delegated to someone else. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Handling Hazardous and Infectious Materials)

Integrated Process: Nursing Process (Assessment) 11. A client arrives at the emergency department following a motor vehicle collision. The client is not awake and is being bagged with a bag-valve-mask by paramedics. The client has sustained obvious injuries to the head and face, as well as an open right femur fracture that is bleeding profusely. What will the nurse do first? a. Splint the right lower extremity. b. Apply direct pressure to the leg. c. Assess for a patent airway. d. Start two large-bore IVs.

C The highest-priority intervention in the primary survey is to establish a patent airway. Without an adequate airway to supply oxygen to the cells, a cerebral injury could progress to anoxic brain death. After an airway is established, resuscitation may continue to B for breathing and C for circulation assessment. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Caring 21. An intensive care nurse is discussing withdrawal of care with a client's family. The family expresses concerns related to discontinuation of therapy. What is the nurse's best response? a. "I understand your concerns, but in this state, discontinuation of care is not a form of active euthanasia." b. "You will need to talk to the provider because I am not legally allowed to participate in the withdrawal of life support." c. "I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death." d. "There is no need to worry. Most religious organizations support the client's decision to stop medical treatment."

C The nurse should validate the family's concerns and provide accurate information about the discontinuation of therapy. The other statements address specific issues related to the withdrawal of care but do not provide appropriate information about its purpose. If the client's family asks for specific information about euthanasia, legal, or religious issues, the nurse should provide unbiased information about these topics. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Nursing Process (Assessment) 9. A nurse is working at the scene of a catastrophic natural event. Which person does the nurse attend to first? a. Distraught mother looking for her children b. Person walking about with a bleeding head wound c. Supine person with pale, cool, clammy skin d. Child with a deformed lower leg crying in pain

C The person with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Caring 24. An emergency department (ED) supervisor has noted an increase in sick calls and bickering among the ED staff after a week with multiple trauma incidents. What action by the supervisor is most helpful? a. Organize a pizza party for each shift. b. Remind staff of facility sick-leave policy. c. Arrange critical incident stress debriefing. d. Talk individually with staff members.

C The staff may be suffering from critical incident stress and needs to have a debriefing by the critical incident stress management team to prevent the consequences of long-term, unabated stress. The other interventions may be helpful as well but are not as important as a debriefing. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Stress Management)

Chapter 12: Concepts of Emergency and Disaster Preparedness Test Bank MULTIPLE CHOICE 1. The nurse has been assigned the role of triage nurse after a weather-related disaster. What is the priority action of the nurse? a. Call in additional staff to assist with care of the victims. b. Splint fractures and clean and dress lacerations. c. Perform a rapid assessment of clients to determine priority of care. d. Provide psychological support to staff and family members.

C The triage nurse classifies victims of the explosion into priority of care based on illness or injury severity. Calling in additional staff more likely would be done by the hospital incident commander or designee. Physical care is provided to victims after triage occurs. Psychological support should be an ongoing part of the disaster plan but is not included in triage responsibilities; this ensures that the greatest good is provided to the greatest number of people. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Communication and Documentation 13. The nurse is caring for a client whose wife just died in an accident. The client says to the nurse, "I can't believe that my wife is gone and I am left to raise my children all by myself." Which response by the nurse is most appropriate? a. "Please accept my sympathy for your loss." b. "I can call the hospital chaplain if you wish." c. "You sound anxious about being a single parent." d. "At least your children still have you in their lives."

C Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the client's distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the client's feelings and situation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

Integrated Process: Nursing Process (Assessment) 18. The nurse is caring for a client who has a moderate head injury. The client's sister asks, "Will my brother return to his normal functioning level when his brain heals?" How does the nurse respond? a. "You should expect a full recovery in all ways by the time of discharge." b. "Usually, someone with this type of injury returns to baseline within 6 months." c. "Your brother may experience many changes in personality and cognitive abilities." d. "Learning complex new skills may be more difficult, but you can expect other functions to return to normal."

C Those with moderate to severe head injuries are never the same as before the injury. They can experience changes in cognition such as memory loss, difficulty learning new information, and limited concentration. Personality alterations such as outbursts of temper and depression also may occur. The other responses do not correctly answer the question and can give false hope. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

Integrated Process: Teaching/Learning 15. The nurse is teaching bladder training to a client who is incontinent after a stroke. Which instruction does the nurse include in this client's teaching? a. "Decrease your oral intake of fluids to 1 liter per day." b. "Use a Foley catheter at night to prevent accidents." c. "Plan to use the commode every 2 hours during the day." d. "Hold your bladder as long as possible to restore bladder tone."

C To begin a bladder training program, teach the client to use the commode, bedpan, or urinal every 2 hours. If used frequently enough, this will prevent accidents and establish a routine. Fluid intake should be restricted at night, and a Foley catheter should be used only for urine retention. The client should empty his or her bladder when the urge occurs and should not hold the bladder. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Implementation) 19. A client who has a severe head injury is placed in a drug-induced coma. The client's husband states, "I do not understand. Why are you putting her into a coma?" How does the nurse respond? a. "These drugs will prevent her from experiencing pain when positioning or suctioning is required." b. "This medication will help her remain cooperative and calm during the painful treatments." c. "This medication will decrease the activity of her brain so that additional damage does not occur." d. "This medication will prevent her from having a seizure and will reduce the need for monitoring intracranial pressure."

C When intracranial pressure cannot be controlled by other means, clients may be placed in a barbiturate coma to decrease cerebral metabolic demands, decrease formation of vasogenic edema, and produce a more uniform blood supply to the brain. The other responses do not correctly explain the reason for a medication-induced coma. Pain medication should be administered when the client is comatose. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Caring 9. The nurse is providing care for a hospice client who is in the last stages of the dying process. The client develops a pressure ulcer on her sacrum, and family members tell the nurse that they would like a specialist consulted to treat the ulcer. When the nurse discusses this with the client, the client states that the ulcer does not bother her, that it is not causing her pain, and that she'd rather not have additional caregivers at this time. What should the hospice nurse do next? a. Tell the family the wound care specialist will be consulted and treatment will begin. b. Ask the social worker and the chaplain to talk with family members about the dying process. c. Explain the client's desires to the family, emphasizing that the client will be made as comfortable as possible. d. Ask the agency mental health nurse to speak with the client about refusing treatment.

C When palliative care is provided to the dying client, symptoms will be actively treated only if they are causing the client distress. In this case, the client has stated that the pressure ulcer is not causing her distress, and she does not want further intervention. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Caring 2. The nurse is providing care for a dying client. The nurse would place highest priority on treating which symptoms? (Select all that apply.) a. Anorexia b. Weight loss c. Pain d. Agitation e. Nausea f. Hair loss g. Dyspnea

C, D, E, G Only symptoms that cause distress for a dying client should be treated. Such symptoms include pain, nausea and vomiting, dyspnea, and agitation. These problems interfere with the client's comfort. Even when symptoms, such as anorexia or weight loss, disturb the family, they should be treated only if the client is distressed by their presence. The nurse should provide education to the family and the client related to normal symptoms of dying. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Nursing Process (Implementation) 2. A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at the nurse when dinner is served late. What is the nurse's best response? a. "Do you need something for pain right now?" b. "Please stop yelling. I brought dinner as soon as I could." c. "I suggest that you get control of yourself." d. "You seem upset. I have time to talk if you like."

D Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the client's options. Simply telling the client to gain control does nothing to promote therapeutic communication. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

Integrated Process: Nursing Process (Assessment) 4. An industrial accident has occurred near the hospital, and many victims are brought to the emergency department (ED) for treatment of their injuries. The nurse triages the victim with which injury with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

D Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the "walking wounded" and classified as nonurgent. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Nursing Process (Assessment) 5. A client who had a stroke combs her hair only on the right side of her head and washes only the right side of her face. How does the nurse interpret these actions? a. Poor left-sided motor control b. Paralysis or contractures on the right side c. Limited visual perception of the left fields d. Unawareness of the existence of her left side

D Clients who have experienced a right hemisphere stroke often have neglect syndrome, in which they are unaware of the existence of the paralyzed side, or the left side. This injury would not have an effect on the client's sight. This is not related to poor motor control or paralysis. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1011 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Potential for Alterations in Body Systems)

Integrated Process: Nursing Process (Analysis) 3. The nurse is caring for an 80-year-old client who presented to the emergency department in a coma. Which question does the nurse ask the client's family to help determine whether the coma is related to a brain attack? a. "How many hours does your mother usually sleep at night?" b. "Did your mother complain recently of weakness in her lower extremities?" c. "Is any history of seizures known among your mother's immediate family?" d. "Does your mother drink any alcohol or take any medications?"

D Conditions such as drug or alcohol intoxication, as well as hypoxemia and metabolic disturbances, can cause profound changes in level of consciousness (LOC) when accompanied by a brain attack. Alcohol abuse and medication toxicity can be especially problematic in older adults. The other manifestations are related to a stroke but would not increase the client's risk of coma. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Caring 18. The nurse is caring for a dying client who becomes very agitated. What is the nurse's best response? a. Use music therapy to promote relaxation. b. Increase the dose of intravenous opioids. c. Provide a second antipsychotic medication. d. Assess the client for urinary retention.

D Dying clients become agitated when they are in pain or have some discomfort. Before administering medications or other therapies to decrease discomfort, the nurse should assess for potential causes of discomfort including urinary retention. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Nursing Process (Planning) 18. The nurse is assessing a client admitted with a brown recluse spider bite. What priority assessment should the nurse perform? a. Ask the client about pruritus at the bite site. b. Inspect for a bluish purple vesicle. c. Assess for redness and swelling. d. Obtain the client's temperature.

D Fever and chills indicate systemic toxicity, which can lead to hemolytic reactions, renal failure, pulmonary edema, cardiovascular collapse, and death. Assessing for a fever should be the nurse's priority. All other symptoms are normal for a brown recluse bite. These should be assessed, but they do not provide information about complications from the bite and therefore are not the priority. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Chapter 9: End-of-Life Care Test Bank MULTIPLE CHOICE 1. The client tells the nurse that even though it has been 4 months since her sister's death, she frequently finds herself crying uncontrollably. The client is afraid that she is "losing her mind." What is the nurse's best response? a. "Most people move on within a few months. You should see a grief counselor." b. "Whenever you start to cry, distract yourself from thoughts of your sister." c. "You should try not to cry. I'm sure your sister is in a better place now." d. "Your feelings are completely normal and may continue for a long time."

D Frequent crying is not an abnormal response. The nurse should let the client know that this is normal and okay. Although the client may benefit from talking with a grief counselor, it is not unusual for her to still be grieving after a few months. The other responses are not as therapeutic because they justify or minimize the client's response. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

Integrated Process: Nursing Process (Implementation) 21. A client with a head injury is being given midazolam (Versed) while on mechanical ventilation. Which action does the nurse implement for this client? a. Monitor for seizures. b. Assess for urinary output. c. Provide a clear liquid diet. d. Administer an analgesic.

D Midazolam (Versed) is a benzodiazepine agent and has no analgesic effect. It should be given with pain medication. This medication does not increase the risk of seizures and does not decrease urinary output. Clients should not be fed when being mechanically ventilated. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Nursing Process (Implementation) 11. On a hot, humid day, several clients present to the emergency department with symptoms of heat exposure. Which client will be treated first? A client who: a. Has normal mental status and flu-like symptoms b. Is diaphoretic with nausea and vomiting c. Is hypotensive and tachycardic d. Is anxious and confused

D Normal mental status, flu-like symptoms, diaphoresis, nausea and vomiting, hypotension, and tachycardia all are symptoms of heat exhaustion. The differentiating symptom between heat exhaustion and exertional heat stroke is the presence of mental status changes, which indicate thermal injury to the brain and represent an emergency situation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Nursing Process (Assessment) 14. The nurse is teaching a client with severe allergies how to prevent bug bites. Which statement by the client indicates that additional teaching is needed? a. "I will avoid wearing perfume when I go outside." b. "I will put the picnic food out when we are ready to eat." c. "I will keep my car windows up at all times." d. "I will wear sandals whenever I go outside."

D Shoes rather than sandals should be worn outside to prevent insect bites. The other statements indicate good understanding of the teaching. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Implementation) 7. Which is the priority action for the emergency department charge nurse in the event of a mass casualty situation? a. Directing medical-surgical and case management nurses to assist emergency department (ED) staff with critically injured victims b. Calling additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in c. Informing the incident commander at the mass casualty scene about how many victims may be handled by the ED d. Directing medical-surgical and critical care nurses to assist with clients who are already in the ED while the ED staff prepares to receive the mass casualty victims

D The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive the mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Concepts of Management)

Integrated Process: Communication and Documentation 6. The nurse manager is assessing current demographics of the facility's emergency department (ED) clients. Which population would most likely present to the ED for treatment of a temperature and a sore throat? a. Older adults b. Immunocompromised people c. Pediatric clients d. Underinsured people

D The ED serves as an important safety net for clients who are ill or injured but lack access to basic health care. Especially vulnerable populations include the underinsured and the uninsured, who may have nowhere else to go for health care. DIF: Cognitive Level: Comprehension/Understanding REF: p. 122 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)

Integrated Process: Caring 5. The spouse of a dying client states that she is concerned that her husband is choking to death. What is the nurse's best response? a. "Do not worry. The choking sound is normal during the dying process." b. "I will administer more morphine to keep your husband comfortable." c. "I can ask the respiratory therapist to suction secretions out through his nose." d. "I will have another nurse assist me to turn your husband on his side."

D The choking sound or "death rattle" is common in dying clients. The nurse should acknowledge the spouse's concerns and provide interventions that will reduce the choking sounds. Repositioning the client onto one side with a towel under the mouth to collect secretions is the best intervention. Morphine will assist with comfort but will not decrease the choking sounds. Nasal tracheal suctioning is not appropriate in a dying client. The nurse should not minimize the spouse's concerns. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Nursing Process (Implementation) 10. The hospital is overwhelmed when caring for victims after an earthquake that occurred 48 hours ago. Which responsibility of the nursing supervisor is most important at this time? a. Assuming leadership for implementation of the hospital emergency plan b. Releasing updates of client conditions to the media c. Converting the physical therapy clinic into a treatment area for the injured d. Arranging relief and coordinating breaks so nursing staff can rest and eat

D The nursing supervisor should ensure that the staff is not becoming dangerously overtired by working long shifts without food or rest. Overall leadership for implementing the emergency plan and re-designating areas for client care would fall under the job of hospital incident commander. The community relations/public information officer would work with the media. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Concepts of Management)

Integrated Process: Nursing Process (Planning) 2. On admission to the emergency department, a client states that he feels like killing himself. When planning this client's care, it is most important for the nurse to coordinate with which member of the health care team? a. Case manager b. Forensic nurse examiner c. Physician d. Psychiatric crisis nurse

D The psychiatric crisis nurse interacts with clients and families in crisis. This health care team member can offer valuable expertise to the emergency health care team, which also includes the case manager and the physician. DIF: Cognitive Level: Comprehension/Understanding REF: p. 122 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team)

Integrated Process: Caring 16. A dying client's family members are spending time with the client. What instruction is best to give to family members regarding noise in the client's room? a. "Remember that she cannot hear you." b. "Try to get her to talk or respond to you." c. "Avoid making any noise when you are with her." d. "Talk in your normal speaking voice."

D The sense of hearing may remain intact, even when it appears that the client is totally unresponsive to any sort of stimuli. The family member should speak to the client as if she were fully aware. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Teaching/Learning 6. A community nurse assesses a client, who has an allergy to bees, after a bee sting. The client's lips are swollen, and wheezes are audible. What is the priority action of the nurse? a. Elevate the site and notify the client's next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine (Benadryl) and apply ice. d. Administer an EpiPen from the first aid kit and call 911.

D The student's swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Nursing Process (Implementation) 4. The emergency department nurse assesses a client in extreme pain with an apparent snakebite of the leg. Vital signs are stable. What is the priority action of the nurse? a. Call the regional poison control center. b. Administer IV pain medication. c. Place a tourniquet around the leg. d. Apply an immobilization splint.

D Treatment involves immobilization to minimize the spread of venom. A tourniquet should not be used because it impairs arterial blood flow. Pain medication should be administered and collaboration with the regional poison control center begun after the leg is immobilized. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Nursing Process (Planning) 10. A nurse is at the scene of a lightning strike during a thunderstorm. Which is the priority action of the nurse? a. Make sure that victims are not electrically charged. b. Assess victims for second- and third-degree burns. c. Start emergency resuscitation on anyone not breathing. d. Move victims and first aid responders to a sheltered area.

D Victims of a lightning strike are not electrically charged afterward. Cardiopulmonary resuscitation (CPR) should be started once victims and first aid responders are in a sheltered area, because the thunderstorm presents a continued threat of lightning strikes. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Caring 10. The nurse is being trained in hospice care. Which intervention by the nurse is most compatible with the goals of end-of-life care for the client? a. Administer influenza and pneumococcal vaccinations. b. Prevent the client with chronic obstructive pulmonary disease from smoking. c. Perform passive range-of-motion exercises to prevent contractures. d. Permit the client with diabetes mellitus to have a serving of ice cream.

D When a client is near the end of life, nursing interventions should be focused toward facilitating peaceful death by granting the client's wishes and identifying his or her needs. Allowing a client who wishes to have something that is not permitted in the diet can be comforting if he or she has a craving or a desire for that food. There is no reason to withhold it at this time. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)

Integrated Process: Nursing Process (Planning) 15. A client in the emergency department has died from a suspected homicide. What is the nurse's priority intervention? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the family's trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the client's death to the family in a simple and concrete manner.

D When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss)

Integrated Process: Nursing Process (Implementation) OTHER 1. The nurse is assessing clients on site at a multi-vehicle accident. Triage clients in the order they should receive care. (Place in order of priority.) a. A 50-year-old with chest trauma and difficulty breathing b. A mother frantically looking for her 6-year-old son c. An 8-year-old with a broken leg in his father's arms d. A 60-year-old with facial lacerations and confusion e. A pulseless male with a penetrating head wound

a, d, b, c, e Clients should be prioritized with ABCs and emergent, urgent, and nonurgent status. The client with chest trauma and difficulty breathing is the priority because no clients have an airway problem, and this is the only client with a breathing problem. The client with confusion should be seen next. Confusion can be caused by lack of oxygen to the brain due to a circulation problem. The pulseless client with a penetrating head wound is seen last because there are multiple clients to be seen, and care for this client would be futile. The client with a broken leg is nonurgent and can wait. The mother looking for her son should be seen third. Finding the child is urgent to identify potential injuries. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)