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A client is rescued after an explosion and reports being thrown against a wall by
the force of the blast. Which type of blast injury does this scenario represent?
Tertiary
A client is found outdoors on a hot day and is brought to the emergency
department. Which assessment findings are most consistent with heat stroke?
hot, dry skin
A client presents with acute ischemic stroke and is being evaluated for tissue
plasminogen activator (TPA) therapy. Which of the following places the client at
risk for complications and may contraindicate tPA administration?
,Active internal bleeding (hemorrhage)
A client presents to the emergency department with fever, headache, and stiff neck.
The nurse notes nuchal rigidity and observes the client squinting and avoiding light
(photophobia). Which condition do these findings most strongly suggest?
meningitis
A client is admitted with a cerebral aneurysm and is at risk for seizures. Which
nursing intervention is the priority?
Pad the side rails
keep oxygen and suction equipment at bedside
position the client on their side during a seizure
A client is admitted after a traumatic brain injury and is suspected of internal
hemorrhaging. Which assessment findings would the nurse most likely observe?
tachycardia
decreased capillary refill
A client is brought to the emergency department after a car accident and is
unconscious. The healthcare provider needs to perform life-saving treatment. What
should the nurse do regarding informed consent?
document that the client is unstable to provide consent and proceed according to
emergency protocols
, A client arrives in the emergency department and requires urgent care. The client's
family states that the situation is life-threatening and requests immediate treatment,
even though the client is alert. Which statement is true regarding emergencies and
consent?
An emergency is defined by what the patient or family perceives as life-threatening
A client arrives in the emergency department with genitourinary trauma and
presents with a distended bladder. Which action should the nurse avoid?
inserting a urinary catheter before surgical clearance
wait for the specialist
A client is admitted with moderate hypothermia after being found outdoors in
freezing temperatures. Which intervention should the nurse implement first to
rewarm the client?
administer warm IV fluids, normal saline or lactated ringers
A client is exposed to a nerve agent during a chemical incident. The nurse notes
salivation, lacrimation, urination, diarrhea, gastrointestinal cramping, and emesis
along with muscle twitching and respiratory distress. What is the most likely
condition?
Cholinergic crisis