Adult Health Exam #3

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action would the nurse take 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 the best neurologic response.

ANS: A After establishing an airway, 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 or she may not be breathing, or may be breathing inadequately with the device in place. Inserting an IV line and placing the client on a monitor would come after ensuring a patent airway and effective breathing.

What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department? a. Determine the acuity of the client's condition to determine priority of care. b. Assess the status of the airway, breathing, circulation, or presence of deficits. c. Determine whether the client is responsive enough to provide needed information. d. Evaluate the emergency department's resources to adequately treat the patient.

ANS: A ED triage is an organized system for sorting and classifying clients into priority levels depending on illness or injury severity. The primary goal of the triage system is to facilitate the ED nurse's ability to prioritize care according to the acuity of the patient, having the clients with the more severe illness or injury seen first. Airway, breathing, and circulation are part of the primary survey. Determining responsiveness is done during the disability phase of the primary survey and is not the primary goal. Evaluating the ED's resources is also not a goal of triage.

A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action? A) Check the patients blood glucose level. B) Assess for a documented history of major depression. C) Determine whether the patient has ingested a corrosive substance. D) Arrange for assessment of serum potassium levels.

ANS: A Hypoglycemia can mimic alcohol intoxication and should be assessed in a patient suspected of alcohol intoxication. Potassium imbalances, depression, and poison ingestion are not noted to mimic the characteristic signs and symptoms of alcohol intoxication.

A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action? A) Perform a rapid physical assessment. B) Initiate health education. C) Perform diagnostic imaging. D) Establish the circumstances of the accident

ANS: A Once immediate threats to life have been corrected, a rapid physical examination is done to identify injuries and priorities of treatment. Health education is initiated later in the care process and diagnostic imaging would take place after a rapid physical assessment. It is not the care teams responsibility to determine the circumstances of the accident.

23. A client is brought to the ED by two police officers. The client was found unconscious on the sidewalk, the client's face and hands covered in blood. At present, the client is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the client in restraints. What action should the nurse perform when the client is restrained? A. Frequently assess the client's skin integrity. B. Inform the client about the likelihood of being charged with assault. C. Avoid interacting with the client until the restraints are removed. D. Take the opportunity to perform a full physical assessment.

ANS: A Rationale: It is important to assess skin integrity when physical restraints are used. Criminal charges are not the responsibility of the nurse and the nurse should still interact with the client. A full physical assessment, however, would likely be delayed until the client is not combative.

17. A homeless person is admitted the ED during a blizzard, and is unable to feel the feet and lower legs. Core temperature is noted at 33.2°C (91.8°F). The client is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurse's priority in the care of this client? A. Addressing the client's hypothermia B. Addressing the client's frostbite in his lower extremities C. Addressing the client's alcohol intoxication D. Addressing the client's malnutrition

ANS: A Rationale: The client may also have frostbite, but hypothermia takes precedence in treatment because it is systemic rather than localized. The alcohol abuse and the alteration in nutrition do not take precedence over the treatment of hypothermia because both problems are a less acute threat to the client's survival.

Which client should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined? A. A client with a blunt chest trauma with some difficulty breathing B. A client with a sore neck who was immobilized in the field on a backboard with a cervical collar C. A client with a possible fractured tibia with adequate pedal pulses D. A client with an acute onset of confusion

ANS: A Rationale: The client with blunt chest trauma possibly has a compromised airway. Establishment and maintenance of a patent airway and adequate ventilation are prioritized over other health problems, including skeletal injuries and changes in cognition.

The paramedics bring a client who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim? A. Respect the client's privacy during assessment. B. Shave all pubic hair for laboratory analysis. C. Place items for evidence in plastic bags. D. Bathe the client before the examination.

ANS: A Rationale: The client's privacy and sensitivity must be respected because the client will be experiencing a stress response to the assault. Pubic hair is combed or trimmed for sampling. Paper bags are used for evidence collection because plastic bags retain moisture, which promotes mold and mildew that can destroy evidence. Bathing the client before the examination would destroy or remove key evidence.

The ED nurse is planning the care of a client who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal? A. Encouraging the client to gain a sense of control over his or her life B. Collecting sufficient evidence to secure a criminal conviction C. Helping the client understand that this will not happen again D. Encouraging the client to verbalize what happened during the assault

ANS: A Rationale: The goals of management are to provide support, to reduce the client's emotional trauma, and to gather available evidence for possible legal proceedings. All of the interventions are aimed at encouraging the client to gain a sense of control over his or her life. The client's well-being should be considered a priority over criminal proceedings. No health professional can guarantee the client's future safety and having the client verbalize the event is not a priority.

A client in the critical care unit is prescribed crystalloid intravenous fluids. The nurse anticipates administering which fluid? Select all that apply. A. Normal saline B. Lactated Ringer C. Dextrose 5% in water D. Albumin E. Hetastarch (TM)

ANS: A, B, C Rationale: These crystalloid solutions in various concentrations and combinations contain electrolytes and sometimes sugars: saline; lactated Ringer; 5% dextrose in water. IV solutions with larger molecules designed to expand IV volume with increased oncotic pressures include: albumin, Hespan, or Hetastarch.

An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information would the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Mechanism of injury b. Diagnostic test results c. Immunizations d. List of home medications e. Isolation Precautions f. Safety concerns

ANS: A, B, E, F Hand-off communication would be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication would be concise and would include only the most essential information for a safe transition in care. Hand-off communication would include the client's situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, safety concerns interventions provided, and response to those interventions. Immunization history is not usually considered critical unless it relates to the reason for admission. Medication reconciliation will occur when the client reaches the inpatient unit.

A client admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this client assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply. A. Dysrhythmias B. Hypothermia C. Hypotension D. Hyperglycemia E. Delirium

ANS: A, C, E Rationale: The client is assessed for signs and symptoms of fluid and electrolyte imbalances, including lethargy, rapid pulse rate, fever, oliguria, anuria, hypotension, and delirium. Hyperglycemia and hypothermia are not typically associated with fluid and electrolyte imbalances.

The complex care provided during an emergency requires interprofessional collaboration. Which team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse—interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis b. Forensic nurse examiner—performs rapid assessments to ensure that clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources c. Triage nurse—provides basic life support interventions such as oxygen, basic wound care, splinting, spinal motion restriction, and monitoring of vital signs d. Emergency medical technician—obtains client histories, collects evidence, and offers counseling and follow up care for victims of rape, child abuse, and domestic violence e. Paramedic—provides prehospital advanced life support, including cardiac monitoring,

ANS: A, E The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client's behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure that clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.

A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first? a. A 22 year old with a painful and swollen right wrist b. A 45 year old reporting chest pain and diaphoresis c. A 60 year old reporting difficulty swallowing and nausea d. An 81 year old, respiratory rate 28 breaths/min and temperature of 101° F (38.8°C)

ANS: 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.

The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives. Which action would the nurse take first? a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he or she wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the patient. d. Refer the client's spouse to the hospital's crisis team.

ANS: 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.

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? a. Level I—located within remote areas and provides advanced life support within resource capabilities b. Level II—located within community hospitals and provides care to most injured clients c. Level III—located in rural communities and provides only basic care to clients d. Level IV—located in large teaching hospitals and provides a full continuum of trauma care for all clients

ANS: B Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher level trauma centers are made.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action would the nurse take prior to 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.

ANS: B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions would 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. It is not known if this client has orthopedic injuries. The Rapid Response Team is not needed in the ED. A complete history is needed but the staff's protection comes first.

The nurse is admitting a client who is suspected of having heat stroke. What assessment finding would be most consistent with this diagnosis? A. Widening pulse pressure B. Hot, dry skin C. Core body temperature of 99.0°F/37.2°C D. Cheyne-Stokes respirations

ANS: B Rationale: Heat stroke is manifested by hot, dry skin, confusion, bizarre behavior, coma, elevated body temperature (usually 103°F/39.4°C or higher), tachypnea, hypotension, and tachycardia. A widening pulse pressure is more indicative of a heart defect or problem. Cheyne-Stokes respirations, a rare condition characterized by fast, shallow breathing followed by slow heavier breathing, followed by no breathing, are typically seen in clients with heart failure and stroke.

A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what? A) Liver B) Small bowel C) Stomach D) Large bowel

ANS: B Penetrating abdominal wounds have a high incidence of injury to hollow organs, especially the small bowel. The liver is also injured frequently, but it is a solid organ.

20. A client is being treated for bites suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action? A. Apply a dressing saturated with chlorhexidine. B. Wash the bites with soap and water. C. Arrange for the client to receive a hepatitis B vaccination. D. Assess the client's immunization history.

ANS: B Rationale: After forensic evidence has been gathered, cleansing with soap and water is necessary, followed by the administration of antibiotics and tetanus toxoid as prescribed. The client's immunization history does not directly influence the course of treatment, and hepatitis B vaccination is not indicated. Chlorhexidine bandages are not recommended.

The nurse observes that the family members of a patient who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family? A) Anxiety and denial B) Remorse and guilt C) Anger D) Grief

ANS: B Remorse and guilt are natural processes of the stages of a crisis and should be facilitated for the family members to process the crisis. The family's sense of blame and responsibility are more suggestive of guilt than anger, grief, or anxiety.

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. What action would the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and reassess in 15 minutes.

ANS: B The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the patient, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this patient's temperature or improve the patient's symptoms. The client needs immediate medical treatment; therefore, rest and reassessing in 15 minutes are inappropriate.

A client is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the client's cardiopulmonary status, the nurse should prepare to perform what intervention? A. Administer a bolus of lactated Ringer. B. Administer naloxone hydrochloride (Narcan). C. Insert an indwelling urinary catheter. D. Perform a focused neurologic assessment.

ANS: B Rationale: Naloxone is an opioid antagonist that is given for the treatment of narcotic overdoses. There is no definitive need for a urinary catheter or for a bolus of lactated Ringer. The client's basic neurologic status should be ascertained during the rapid assessment, but a detailed examination is less important than administration of an antidote.

A client with a history of major depression is brought to the ED by the client's parents. Which of the following nursing actions is most appropriate? A. Noting that symptoms of physical illness are not relevant to the current diagnosis B. Asking if the client has ever thought about taking their own life C. Conducting interviews in a brief and direct manner D. Arranging for the client to spend time alone to consider their feelings

ANS: B Rationale: Establishing if the client has suicidal thoughts or intents helps identify the level of depression and intervention. Physical symptoms are relevant and should be explored. Allow the client to express feelings, and conduct the interview at a comfortable pace for the client. Never leave the client alone because suicide is usually committed in solitude.

The ED nurse admitting a client with a history of depression is screening the client for suicide risk. What assessment question should the nurse ask when screening the client? A. "How would you describe your mood over the past few days?" B. "Have you ever thought about taking your own life?" C. "How do you think that your life is most likely to end?" D. "How would you rate the severity of your depression right now on a 10-point scale?"

ANS: B Rationale: The nurse should address the client's possible plans for suicide in a direct yet empathic manner. The nurse should avoid oblique or indirect references to suicide and should not limit questions to the client's depression.

A client with multiple injuries is brought to the emergency department by ambulance. The client has had his airway stabilized and is breathing on their own. The nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A. Absence of bruising at contusion sites B. Rapid pulse and decreased capillary refill C. Increased BP with narrowed pulse pressure D. Sudden diaphoresis

ANS: B Rationale: The nurse would anticipate that the pulse would increase and BP would decrease. Urine output would also decrease. An absence of bruising and the presence of diaphoresis would not suggest internal hemorrhage.

24. An emergency department (ED) nurse is triaging clients according to a triage severity rating. When assigning clients to a triage level, the nurse will consider the clients' acuity as well as what other variable? A. The likelihood of a repeat visit to the ED in the next seven days B. The resources that the client is likely to currently require C. The client's or insurer's ability to cover the cost of care D. Whether other hospitals are on diversionary status and ability to manage the client

ANS: B Rationale: With the emergency severity index (ESI), clients are assigned to triage levels based on both their acuity and their anticipated resource needs. ESI is a triage algorithm. The rating is from 1 to 5 with the most urgent clients rated as a 1 and the least urgent a 5. Ability to participate, the likelihood of repeat visits, and other hospitals' ability to take clients are not explicitly considered.

A nurse is caring for clients in a busy emergency department. What actions would the nurse take to ensure client and staff safety? (Select all that apply.) a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information. e. Use facility policy identification procedures for "Jane/John Doe" clients. f. Check clients for a medical alert bracelets or necklaces. g. Avoid using Security personnel to prevent escalation of client behaviors.

ANS: B, C, D, E, F Best practices for client and staff safety in the emergency department include leaving beds in the lowest position with side rails up, using two unique identifiers for medications and procedures, using de-escalation strategies for clients or visitors showing hostile or aggressive behaviors, searching the belongings of confused clients for medical information, using facility identification systems for Jane/John Doe clients, observing for medical alert jewelry, and using security staff as needed.

An emergency department nurse is caring for a trauma patient. Which interventions does the nurse perform during the primary survey? (Select all that apply.) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair

ANS: B, C, E, 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: Airway and cervical spinal motion restriction; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.

A nurse is triaging clients in the emergency department. Which client would the nurse classify as "nonurgent?" a. A 44 year old with chest pain and diaphoresis b. A 50 year old with chest trauma and absent breath sounds c. A 62 year old with a simple fracture of the left arm d. A 79 year old with a temperature of 104° F (40.0° C)

ANS: 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 a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. 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.

A nurse is triaging clients in the emergency department. Which client would be considered "urgent"?

ANS: C A client with a cough and a temperature of 102° F (38.9° C) is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech would 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.

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action would the nurse take first? a. Apply oxygen via nasal cannula. b. Administer intravenous 0.9% saline solution. c. Transfer the client to a negative-pressure room. d. Obtain a sputum culture and sensitivity.

ANS: C A client with signs and symptoms of tuberculosis or other airborne pathogens would be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department. The client may or may not need oxygen or an IV. A sputum culture would be obtained but is not the priority.

An emergency department nurse assesses a client who has been raped. With which health care team member would the nurse collaborate when planning this client's care? a. Primary health care provider b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

ANS: 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.

An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention would the case manager provide? 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.

ANS: 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 provider 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.

A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions? A) Insert an oropharyngeal airway. B) Perform the jaw thrust maneuver. C) Perform endotracheal intubation. D) Perform a cricothyroidotomy.

ANS: C Feedback: Endotracheal tubes are used in cases when the patient cannot be ventilated with an oropharyngeal airway, which is used in patients who are breathing spontaneously. The jaw thrust maneuver does not establish an airway and cricothyroidotomy would be performed as a last resort.

An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48 year old with a simple fracture of the lower leg

ANS: C The client with pale, cool, clammy skin may be 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.

A client with multiple trauma is brought to the emergency department (ED) by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this client's care? A. Intubating the client B. Notifying family members C. Ensuring Intravenous (IV) access D. Testing laboratory specimens

ANS: C Rationale: ED nursing responsibilities include ensuring airway and IV access. Nurses are not normally responsible for notifying family members. Nurses collect specimens, but are not responsible for testing . Health care providers or other team members with specialized training intubate the client.

A patient is brought to the ED by family members who tell the nurse that the patient has been exhibiting paranoid, agitated behavior. What should the nurse do when interacting with this patient? A) Keep the patient in a confined space. B) Use therapeutic touch appropriately. C) Give the patient honest answers about likely treatment. D) Attempt to convince the patient that his or her fears are unfounded.

ANS: C The nurse should offer appropriate and honest explanations in order to foster rapport and trust. Confinement is likely to cause escalation, as is touching the patient. The nurse should not normally engage in trying to convince the patient that his or her fears are unjustified, as this can also cause escalation.

An elderly client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient? a. A full set of vital signs b. Cardiac rhythm c. Neurologic status d. Client history

ANS: C The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. Injuries from this type of fall have a high risk for cervical spine injuries. In addition, with the loss of consciousness at the scene the client would be at risk for head trauma. A full set of vital signs is obtained as part of the secondary survey. The cardiac rhythm is important but not specifically related to this client's presentation. Client history would be obtained as able.

An emergency department nurse is caring for a client who is homeless. Which action would the nurse take to gain the client's trust? a. Speak in a quiet and monotone voice. b. Avoid eye contact with the patient. c. Listen to the client's concerns and needs. d. Ask security to store the client's belongings.

ANS: C To demonstrate behaviors that promote trust with homeless clients, the emergency department nurse makes eye contact (if culturally appropriate), speaks calmly, avoids any prejudicial or stereotypical remarks, shows genuine care and concern by listening, and follows through on promises. The nurse would also respect the client's belongings and personal space.

A client is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The client is alert and oriented. What is the care team's most appropriate treatment? A. Administering syrup of ipecac B. Performing a gastric lavage C. Giving milk to drink D. Referring to psychiatry

ANS: C Rationale: A client who has swallowed an acidic substance, such as toilet bowl cleaner, may be given milk or water to drink for dilution. Gastric lavage must be performed within 1 hour of ingestion. A psychiatric consult may be considered once the client is physically stable and it is deemed appropriate by the health care provider. Syrup of ipecac is no longer used in clinical settings.

A client has sustained multiple injuries from a gunshot wound while hunting in cold winter weather. The client has waited several hours for rescue and is transported in a helicopter to the emergency department. The nurse recognizes what additional factors are associated with increased mortality for this client? A. Time of injury, hyperhidrosis, and thermal changes B. Comorbidities, location of injury, and gravitational forces C. Hypothermia, acidosis, and coagulopathy D. Venous insufficiency, barometric changes, and fatigue

ANS: C Rationale: Major trauma can cause hypothermia, acidosis, and coagulopathy, sometimes called the "triad of death" because each of these factors is associated with increased mortality. In this case the client was exposed to cold weather for several hours. The client had a gunshot wound that caused bleeding. Coagulopathy likely occurs immediately after massive trauma and shock. As the client with trauma perfusion worsens, lactic acid rapidly accumulates in the tissues, which ultimately results in severe metabolic acidosis. Thermal changes, gravitational forces, barometric changes, and fatigue are all related to stresses of flight, but they are not directly related to an increased mortality. Comorbidities, time, and location of injury can contribute to the client's survivability but are paired with choices that do not. Venous insufficiency and hyperhidrosis (excessive sweating) are not directly linked to this event.

The nurse is caring for a client with alcohol withdrawal syndrome. What would be an appropriate nursing action to minimize the potential for hallucinations? A. Engage the client in a process of health education. B. Administer opioid analgesics as prescribed. C. Place the client in a private, well-lit room. D. Provide television or a radio as therapeutic distraction

ANS: C Rationale: The client should be placed in a quiet single room with lights on and in a calm, nonstressful environment. TV and radio stimulation should be avoided. Analgesics are not normally necessary, and would potentially contribute to hallucinations. Health education would be inappropriate while the client is experiencing acute withdrawal.

A client with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the client's injuries? A. Myocardial infarction B. Hypoglycemia C. Hemorrhage D. Peritonitis

ANS: C Rationale: The signs and symptoms the client is experiencing suggest a volume deficit from an internal bleed. That the symptoms follow an acute injury suggests hemorrhage rather than myocardial infarction or hypoglycemia. Peritonitis would be an unlikely result of a femoral fracture.

A client is brought by friends to the ED after being involved in a motor vehicle accident. The client sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this client? A. Ambulate the client to expel flatus. B. Place the client in a high Fowler position. C. Immobilize the client on a backboard. D. Place the client in a left lateral position.

ANS: C Rationale: When admitted for blunt trauma, clients must be immobilized until spinal injury is ruled out. Ambulation, side-lying, and upright positioning would be contraindicated until spinal injury is ruled out.

A patient is brought to the ER in an unconscious state. The physician notes that the patient is in need of emergency surgery. No family members are present, and the patient does not have identification. What action by the nurse is most important regarding consent for treatment? A) Ask the social worker to come and sign the consent. B) Contact the police to obtain the patients identity. C) Obtain a court order to treat the patient. D) Clearly document LOC and health status on the patients chart.

ANS: D Feedback: When patients are unconscious and in critical condition, the condition and situation should be documented to administer treatment quickly and timely when no consent can be obtained by usual routes. A social worker is not asked to sign the consent. Finding the patients identity is not a priority. Obtaining a court order would take too long.

An emergency department nurse is caring for a client who has died from a suspected homicide. Which action does the nurse take? 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.

ANS: 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 would be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee would be consulted, but this is not the priority at this time.

A client who has been diagnosed with cholecystitis is being discharged home from the ED to be scheduled for later surgery. The client received morphine during the present ED admission and is visibly drowsy. When providing health education to the client, what would be the most appropriate nursing action? A. Give written instructions to client. B. Give verbal instructions to one of the client's family members. C. Telephone the client the next day with verbal instructions. D. Give verbal and written instructions to the client and a family member.

ANS: D Rationale: Before discharge, verbal and written instructions for continuing care are given to the client and the family or significant others. Discharge teaching is completed prior to the client leaving the ED, so phoning the client the next day is not acceptable.

A client who attempted suicide is being treated in the ED. The client is accompanied by the client's mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following actions? A. Refer the family to a psychiatrist in order to provide them with support. B. Explore the causes of the client's suicide attempt with the family. C. Encourage the family to participate in the bedside care of the client. D. Ensure that the family receives appropriate crisis intervention services.

ANS: D Rationale: It is essential that family crisis intervention services are available for families of ED clients. It would be inappropriate and insensitive to explore causes of the client's suicide attempt with the family. Family participation in bedside care is often impractical in the ED setting. Psychiatry is not the normal source of psychosocial support and crisis intervention.

An obtunded client is admitted to the ED after ingesting bleach. The nurse should prepare to assist with what intervention? A. Prompt administration of an antidote B. Gastric lavage C. Administration of activated charcoal D. Helping the client drink large amounts of water

ANS: D Rationale: The client who has ingested a corrosive poison, such as bleach, is given water or milk to drink for dilution. Gastric lavage is not used to treat ingestion of corrosives and activated charcoal is ineffective. There is no antidote for a corrosive substance such as bleach.

A client has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the client's bladder is distended. What is the nurse's most appropriate action? A. Withhold fluids from the client. B. Perform intermittent urinary catheterization. C. Insert a narrow-gauge indwelling urinary catheter. D. Await orders following the urologist's assessment.

ANS: D Rationale: Urethral catheter insertion when a possible urethral injury is present is contraindicated; a urology consultation and further evaluation of the urethra are required. The nurse would withhold fluids, but urologic assessment is the priority.

A client is brought to the emergency room (ER) in an unconscious state and emergency surgery is needed. No family members are present, and the client does not have identification. What action by the nurse is the priority regarding consent for treatment? A. Ask the social worker to come and sign the consent. B. Contact the police to obtain the client's identity. C. Obtain an emergency court order to treat the client. D. Clearly document level of consciousness (LOC) and health status on the client's chart.

ANS: D Rationale: When clients are unconscious and in critical condition, the condition and situation should be documented to administer treatment quickly and timely when no consent can be obtained by usual routes. According to the Emergency Medical Treatment and Active Labor Act (EMTALA), every ED with a Medicare provider agreement must perform a medical screening examination on all clients arriving with an emergency medical issue if their acute signs and symptoms could result in serious injury or death if left untreated. EDs are also required to provide treatment aimed at stabilizing each client's condition. A social worker is not asked to sign the consent. Finding the client's identity is not a priority. Obtaining a court order would take too long.

A nurse prepares to discharge an older adult client home from the emergency department (ED). What actions does the nurse take to prevent future ED visits? (Select all that apply.) a. Provide medical supplies to the family. b. Consult a home health agency. c. Encourage participation in community activities. d. Screen for depression and suicide. e. Complete a functional assessment.

ANS: D, E Due to the high rate of suicide among older adults, a nurse would assess all older adults for depression and suicide. The nurse would also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits.

A patient is admitted to the ED after being involved in a motor vehicle accident. The patient has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care? A) Control the patients hemorrhage. B) Assess for cognitive effects of the injury. C) Splint the patients fractures. D) Assess the patients neurologic status.

Ans: A Feedback: After establishing airway and ventilation, the team should evaluate and restore cardiac output by controlling hemorrhage. This must precede neurologic assessments and treatment of skeletal injuries.

An 83-year-old patient is brought in by ambulance from a long-term care facility. The patients symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage. Why would this be true? A) Older adults may have an altered response to treatment. B) Older adults are often reluctant to adhere to prescribed treatment. C) Older adults have difficulty giving a health history. D) Older adults often stigmatize their peers who use the ED.

Ans: A Feedback: Emergencies in this age group may be more difficult to manage because elderly patients may have an atypical presentation, an altered response to treatment, a greater risk of developing complications, or a combination of these factors. The elderly patient may perceive the emergency as a crisis signaling the end of an independent lifestyle or even resulting in death. Stigmatization and nonadherence to treatment are not commonly noted. Older adults do not necessarily have difficulty giving a health history.

A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the patients frostbite? A) Immerse affected extremities in water slightly above normal body temperature. B) Immerse the patients frostbitten extremities in the warmest water the patient can tolerate. C) Gently massage the patients frozen extremities in between water baths. D) Perform passive range-of-motion exercises of the affected extremities to promote circulation.

Ans: A Feedback: Frozen extremities are usually placed in a 37C to 40C (98.6F to 104F) circulating bath for 30- to 40-minute spans. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

The nurse is caring for a patient admitted with a drug overdose. What is the nurses priority responsibility in caring for this patient? A) Support the patients respiratory and cardiovascular function. B) Provide for the safety of the patient. C) Enhance clearance of the offending agent. D) Ensure the safety of the staff.

Ans: A Feedback: Treatment goals for a patient with a drug overdose are to support the respiratory and cardiovascular functions, to enhance clearance of the agent, and to provide for safety of the patient and staff. Of these responsibilities, however, support of vital physiologic function is a priority.

A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient? A) Assessing the patients oral temperature frequently B) Ensuring continuous ECG monitoring C) Massaging the patients skin surfaces to promote circulation D) Administering bronchodilators by nebulizer

Ans: B Feedback: A hypothermic patient requires continuous ECG monitoring and assessment of core temperatures with an esophageal probe, bladder, or rectal thermometer. Massage is not performed and bronchodilators would normally be insufficient to meet the patients respiratory needs.

A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patients peritoneum, the nurse should anticipate what diagnostic test? A) Radiograph B) Computed tomography (CT) scan C) Complete blood count (CBC) D) Barium swallow

Ans: B Feedback: CT scan of the abdomen, diagnostic peritoneal lavage, and abdominal ultrasound are appropriate diagnostic tools to assess intra-abdominal injuries. X-rays do not yield sufficient data and a CBC would not reveal the presence of intraperitoneal injury.

The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses who provide care in a desert region. The educator should describe what sign or symptom? A) Hypertension with a wide pulse pressure B) Anhidrosis C) Copious diuresis D) Cheyne-Stokes respirations

Ans: B Feedback: Heat stroke is manifested by anhidrosis confusion, bizarre behavior, coma, elevated body temperature, hot dry skin, tachypnea, hypotension, and tachycardia. This health problem is not associated with anhidrosis or Cheyne-Stokes respirations.

A patient is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply. A) Ascites B) Rebound tenderness C) Changes in bowel sounds D) Muscular rigidity E) Copious diarrhea

Ans: B, C, D Signs of peritoneal irritation include abdominal distention, involuntary guarding, tenderness, pain, muscular rigidity, or rebound tenderness along with changes in bowel sounds. Diarrhea and ascites are not signs of peritoneal irritation.

A patient is brought to the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temperature of 40.1C(104.2F). What would be the priority nursing action for this patient? A) Monitor cardiovascular effects. B) Administer antipyretics. C) Ensure airway and ventilation. D) Prevent seizure activity.

Ans: C Feedback: Although all of the listed actions may be necessary for this patients care, the priority is to establish a patent airway and adequate ventilation.

A 23-year-old woman is brought to the ED complaining of stomach cramps, nausea, vomiting, and diarrhea. The care team suspects food poisoning. What is the key to treatment in food poisoning? A) Administering IV antibiotics B) Assessing immunization status C) Determining the source and type of food poisoning D) Determining if anyone else in the family is ill

Ans: C Feedback: Determining the source and type of food poisoning is essential to treatment, and is more important than determining other sick family members. Antibiotics are not normally indicated and immunizations are not relevant to diagnosis or treatment of food poisoning.

A triage nurse is talking to a patient when the patient begins choking on his lunch. The patient is coughing forcefully. What should the nurse do? A) Stand him up and perform the abdominal thrust maneuver from behind. B) Lay him down, straddle him, and perform the abdominal thrust maneuver. C) Leave him to get assistance. D) Stay with him and encourage him, but not intervene at this time.

Ans: D Feedback: If the patient is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the patient standing. If the patient is unconscious, the nurse should lay the patient down. A nurse should never leave a choking patient alone.

A nurse is caring for a patient who has been the victim of sexual assault. The nurse documents that the patient appears to be in a state of shock, verbalizing fear, guilt, and humiliation. What phase of rape trauma syndrome is this patient most likely experiencing? A) Reorganization phase B) Denial phase C) Heightened anxiety phase D) Acute disorganization phase

Ans: D Feedback: The acute disorganization phase may manifest as an expressed state in which shock, disbelief, fear, guilt, humiliation, anger, and other such emotions are encountered. These varied responses to the assault are not associated with a denial, heightened anxiety, or reorganization phase.

An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patients acuity as well as what other variable? A) The likelihood of a repeat visit to the ED in the next 7 days B) The resources that the patient is likely to require C) The patients or insurers ability to pay for care D) Whether the patient is known to ED staff from previous visits

Feedback: With the ESI, patients are assigned to triage levels based on both their acuity and their anticipated resource needs. Ability to pay, the likelihood of repeat visits, and the history of prior visits are not explicitly considered.