Sr Med Surg PrepU Ch 72: Emergency Nursing

The health care team in an intensive care unit have experienced a critical incident in which a young client died unexpectedly and the client's father physically attacked the senior physician treating the client. The client's father was arrested and escorted from the intensive care unit by police, against his will and in handcuffs. A critical incident stress management (CISM) staff meeting held 3 days after the incident took place. What would be the purpose for that meeting?

debriefing

A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding?

delayed capillary refill

The nurse has come on shift to find that a client newly admitted to the ICU is confused and persistently trying to get out of bed despite being comforted and re-oriented by the nurse. The client begins to pull on the peripheral intravenous line in the hand and speaking in non-sensical terms. The client's history indicates a sudden onset of neurological symptoms after developing a bacterial infection. The nurse anticipates providing care for which health problem?

delirium

The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey?

diagnostic and laboratory testing

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse?

ensure a patent airway and that patient is receiving 100% oxygen

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma?

gunshot wound, knife stab wound

The nurse is caring for a victim of a sexual assault. The client is fearful and experiencing flashbacks. The nurse recognizes that the client is experiencing which phase of the psychological reaction to rape?

heightened anxiety phase

Which phase of the psychological reaction to rape is characterized by fear and flashbacks?

heightened anxiety phase

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following?

high-pitched noise on inhalation

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock?

hypovolemia

A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?

increasing heart rate

Nursing students are reviewing information about anaphylactic reactions and their possible causes. The students demonstrate understanding of this information when they identify which of the following as a common cause?

insect stings, medications, latex, eggs, shellfish, peanuts

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway?

jaw-thrust

The nurse is caring for a victim of a sexual assault. The client is fearful and experiencing flashbacks. The nurse recognizes that the client is experiencing which phase of the psychological reaction to rape?

liver

Which solid organ is most frequently injured in a penetrating trauma?

liver

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate?

massaging the feet

When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate?

positioning the hands in the midline slightly above the umbilicus

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

protecting himself or herself

A client is admitted to the ED after a near-drowning accident. The client is diagnosed with saltwater aspiration. The nurse will observe the client for several hours to monitor for symptoms of

pulmonary edema

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose?

pulmonary edema

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

rinsing the area w/copious amounts of water

The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action?

run a normal saline line to keep the vein open

Following a motor vehicle collision, a client is brought to the ED for evaluation and treatment. The client is being assessed for intra-abdominal injuries. The client reports severe left shoulder pain (pain score of 10 on a 1 to 10 scale). The nurse suspects injury to the

spleen

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

stab

A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?

support the client's emotional status

What are some signs of internal bleeding?

tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill

The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason?

the client requires total parenteral nutrition

Permanent brain injury or death will occur within which time frame secondary to hypoxia?

3 to 5 minutes

A client presents to the ED following a motor vehicle collision. The client is suspected of having internal hemorrhage. The nurse assesses the client for signs and symptoms of shock. Which are signs and symptoms of shock?

Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill

The nurse is assigned to a client admitted to the ICU from the emergency department. The client sustained multiple injuries from a motor vehicle accident. When reviewing the client chart, the notes indicate the client's emergency care was managed in what sequence of steps?

Establish airway and start ventilation Application of pressure to control abdominal bleeding Start peripheral intravenous insertion and infusion of fluids Assess for head and neck injuries Examine client for additional injuries to the body Reassess pulses and neurovascular status

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate?

Patient with an obstructed larynx Patient with extensive facial trauma Patient with laryngeal edema secondary to anaphylaxis

The nurse educator is explaining the difference between indications for nasopharyngeal airway insertion versus endotracheal intubation. Which responses from learners indicate correct reasons for the use of endotracheal tubes in clients?

To bypass an upper airway obstruction To support connecting to mechanical ventilation To facilitate removal of tracheobronchial secretions

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's:

blood pressure

In clients with carbon monoxide poisoning, the central nervous system signs such as

headache and confusion

What occurs during stage II of lyme disease?

joint pain, memory loss, poor motor coordination, and meningitis

What may pain in the right shoulder indicate?

laceration of liver

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

the tongue

A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose?

urgent

The nurse in the hospital emergency department is assessing a patient who fell while intoxicated with alcohol. The nurse is using the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale to assess the patient's need for a benzodiazepine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient?

Are you hearing anything that is disturbing you?

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

My brother got sick like me after eating the same food

Which of the follow are examples of blunt trauma?

falling off a roof, being struck by a baseball bat, motor-vehicle crash

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in?

stage III

The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued?

4%

Several clients in the emergency department are being categorized by the triage nurse. Which client will the nurse place in the urgent category?

A 54-year-old client with a history of diabetes presenting with anemia and abdominal pain

A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do?

Ask the family if they would like to view the body Provide a private place for the family to be together Allow the family to express their emotions freely

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

Brightly colored clothes help to ward off bees

A nurse is preparing an in-service education program about emergency nursing to a group of newly hired nurses who will be working in the emergency department. When describing the current status of visits to the emergency department, which of the following would the nurse include in the presentation?

Clients with Medicaid use the emergency department more often than clients with private health insurance

Which statement reflects the nursing management of the client with a white phosphorus chemical burn?

do not apply water to the burn

A client presents to the ED reporting choking on a chicken bone. The client is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which action should the nurse do next?

encourage the client to cough forcefully

A patient arrives at the emergency department after taking more than 20 lorazepam tablets. Which of the following would the nurse anticipate that the patient would be given to reverse the effects of the drug?

flumazenil

The nurse is administering antivenin to a patient who was bitten on the arm by a venomous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after?

measure the circumference of the arm

A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion?

tissue tearing away from supporting structures

When is cricothyroidotomy used in emergencies?

when endotracheal intubation is either not possible or contraindicated

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure?

administer an analgesic as ordered

The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action?

administer analgesic medications as ordered

The nurse is caring for a client who has just been intubated and started on mechanical ventilation in the intensive care unit. The nurse recognizes that it is possible to inadvertently intubate the right lung only. What nursing assessment and monitoring is required to determine if this complication has occurred?

auscultate both sides of the chest, mark the endotracheal tube at the corner of the mouth & nose, monitor for both high & low pressure alarms

When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable?

cherry red skin color

What occurs during stage I of lyme disease?

classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache

Which term refers to injuries that occur when a person is caught between objects, run over by a moving vehicle, or compressed by machinery?

crush injuries

A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do?

Document the client's condition and absence of friends or family for obtaining consent to treatment

A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse?

Have the patient lie down and place the arm below the level of the heart

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

Let's talk about this. Do you want me to call a support person?