Chapter 72: Emergency Nursing (Suddarth) Exam Latest Updates

Chapter 72: Emergency Nursing (Suddarth) 1. Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? A) A patient with a blunt chest trauma with some difficulty breathing B) A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar C) A patient with a possible fractured tibia with adequate pedal pulses D) A patient with an acute onset of confusion - Ans: A Feedback: The patient with blunt chest trauma possibly has a compromised airway. Establishment and maintenance of a patent airway and adequate ventilation is prioritized over other health problems, including skeletal injuries and changes in cognition. 2. 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 - : B Feedback: 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 familys sense of blame and responsibility are more suggestive of guilt than anger, grief, or anxiety. 3. 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 Feedback: 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. 4. 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 Feedback: 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. 5. 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 - 1351 D) Cheyne-Stokes respirations - : 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. 6. A patient is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The patient is alert and oriented. What is the care teams most appropriate treatment? A) Administering syrup of ipecac B) Performing a gastric lavage C) Giving milk to drink D) Referring to psychiatry - ans: C Feedback: A patient 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 patient is physically stable and it is deemed appropriate by the physician. Syrup of ipecac is no longer used in clinical settings. 7. 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 Feedback: 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. 8. The paramedics bring a patient 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 patients privacy during assessment. B) Shave all pubic hair for laboratory analysis. C) Place items for evidence in plastic bags. D) Bathe the patient before the examination. - : A Feedback: The patients privacy and sensitivity must be respected, because the patient 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 patient before the examination would destroy or remove key evidence. 9. A patient with a history of major depression is brought to the ED by her 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 the patient if she has ever thought about taking her own life C) Conducting interviews in a brief and direct manner D) Arranging for the patient to spend time alone to consider her feelings - : B Feedback: Establishing if the patient has suicidal thoughts or intents helps identify the level of depression and intervention. Physical symptoms are relevant and should be explored. Allow the patient to express feelings, and conduct the interview at a comfortable pace for the patient. Never leave the patient alone, because suicide is usually committed in solitude. - 1353 10. 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.