Latest Update For Brunner & Suddarth's Textbook Of Medical-Surgical Nursing Newest 14th Edition By Janice L. Hinkle with correct Questions and answers (Graded A+)

Latest Update For Brunner & Suddarth's Textbook Of Medical-Surgical Nursing Newest 14th Edition By Janice L. Hinkle with correct Questions and answers (Graded A+) The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities effectively in a client experiencing a trauma. Which action is completed by the nurse when implementing the "D" element of this method? a. Assessing the client's Glasgow Coma Scale score b. Managing hypothermia c. Providing cervical spine protection d. Undressing the client quickly - ANSWER a. Assessing the client's Glasgow Coma Scale score The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. While implementing the D element, the nurse determines neurologic disability by assessing neurologic function using the Glasgow Coma Scale and performing a motor and sensory evaluation of the spine. A quick neurologic assessment may be performed using the AVPU mnemonic: A, alert: is the client alert and responsive? V, verbal: does the client respond to verbal stimuli? P, pain: does the client respond only to painful stimuli? U, unresponsive: is the client unresponsive to all stimuli, including pain? The other interventions are not included in this element of the primary survey. A client presents to the ED following a chemical burn. The client identifies the source of the burn as white phosphorus. The nurse knows that treatment will include a. immediately drenching the skin with running water from a shower, hose, or faucet. b. alternately applying water and ice to the burn. c. No application of water to the burn. d. washing off the chemical using warm water, then flushing the skin with cool water. - ANSWER c. No application of water to the burn. Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or for deepening of the burn. All evidence of these chemicals should be brushed off the client before any flushing occurs. 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? a. Bradycardia b. Rising blood pressure c. Delayed capillary refill d. Pale pink dry skin - ANSWER c. Delayed capillary refill If a client exhibits tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill, internal bleeding should be suspected. A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.) a. Applying a clean dressing to protect the wound b. Elevating the site to limit the accumulation of fluid in the interstitial spaces c. Inserting an indwelling catheter d. Splinting the wound in a position of rest to prevent motion e. Performing a fasciotomy - ANSWER a. Applying a clean dressing to protect the wound b. Elevating the site to limit the accumulation of fluid in the interstitial spaces d. Splinting the wound in a position of rest to prevent motion Major soft tissue injuries are dressed and splinted promptly to control bleeding and pain. If an extremity is injured, it is elevated to relieve swelling and pressure. 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? a. Encourage the client to cough forcefully. b. Insert a nasopharyngeal airway. c. Prepare the client for a bronchoscopy. d. Insert an oropharyngeal airway. - ANSWER a. Encourage the client to cough forcefully. If the client can breathe and cough spontaneously, a partial obstruction should be suspected. The client is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. Suppose the client demonstrates a weak, ineffective cough, a high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis. In that case, the client should be managed as if there were complete airway obstruction. If the client is unconscious, inspection of the oropharynx may reveal the offending object. X-ray study, laryngoscopy, or bronchoscopy also may be performed. There is no indication that an artificial airway is indicated. After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position? a. Just below the tip of the patient's nose b. Approximately at the patient's lips c. Directly in front of the patient's teeth d. At the level of the patient's epiglottis - ANSWER b. Approximately at the patient's lips When an oropharyngeal airway is properly inserted, the tip is in the hypopharynx and the flange is approximately at the patient's lips. The nurse is caring for a client in the intensive care unit who is recovering from trauma as a result of a motor vehicle accident that claimed the life of the client's friend. While the nurse is performing a dressing change on the client's surgical wound, the client states, "I don't deserve to live. I have just been thinking about ending it all." As the nurse assesses the client's imminent risk for suicide, what contributing factors need to be considered? Select all that apply. a. The client attempted suicide as a teenager. b. The client's maternal uncle committed suicide. c. The client's parents visit on a daily basis. d. The client had a close relationship to the accident victim. e. The client is not able to ambulate unassisted. - ANSWER a. The client attempted suicide as a teenager. b. The client's maternal uncle committed suicide. d. The client had a close relationship to the accident victim. When assessing a client's suicide risk, it is very important to first determine whether the client has a previous history of suicide attempts. Having a suicide-attempt history increases the risk that the client will attempt to end his or her life if experiencing suicidal thoughts. Having a family member who has committed suicide increases the risk that the client will follow through with a suicide attempt. Family support mitigates the risk that the client will follow through with a suicide attempt if the client is experiencing hopeless thoughts. Having a close relationship with the victim in the car accident indicates the client is experiencing grief and loss and may increase the risk of suicide. If the client is unable to ambulate unassisted, this decreases the client's means to access to be able to follow through with a suicide attempt. 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? Select all that apply. a. Cool, moist skin b. Decreasing blood pressure c. Increasing heart rate d. Delayed capillary refill e. Increasing urine volume - ANSWER a. Cool, moist skin b. Decreasing blood pressure c. Increasing heart rate d. Delayed capillary refill Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume. A woman is brought to the emergency department by her husband, who reports that his wife "accidentally fell down a flight of steps and broke her arm." The patient is very quiet and withdrawn. During the examination, inspection reveals numerous bruises at different stages of healing over the patient's legs, arms, and abdomen. The nurse suspects abuse. Which of the following questions would be most appropriate for the nurse to use to gather additional information? a. "You have bruises all over your body. Your husband is beating you, isn't he?" b. "I've noticed several bruises here and there. Can you tell me what happened?" c. "Now tell me, did you really fall down the stairs like your husband said?" d. "Your husband has no right to do this to you. Do you want me to call the police?" - ANSWER b. "I've noticed several bruises here and there. Can you tell me what happened?" Approaching the subject of abuse requires a nonthreatening approach that allows the patient to feel comfortable and trusting of the nurse. Therapeutic communication techniques with skillful interviewing are key. Acknowledging the evidence of the bruises and then asking the patient about them is a broad opening statement that allows the patient to direct the response. It also is nonthreatening to the patient and facilitates the development of trust. Questioning the patient about her husband "beating her" indicates that the nurse already assumes this to be the case. It is threatening to the patient and may add to her anxiety and fear levels. Asking the patient if she really fell down the stairs can sound accusatory. The patient may believe the nurse is implying that the patient is lying, which would be nontherapeutic. Although it is true that the husband has no right to abuse his wife, telling the patient this and offering to call the police can be too overwhelming for her at this time. A nurse is performing triage at the scene of a building collapse and is using a five-level triage system. Place the categories below in the proper order from most to least immediate. a. Urgent b. Resuscitation c. Emergent d. Nonurgent e. Less urgent - ANSWER b. Resuscitation c. Emergent a. Urgent e. Less urgent d. Nonurgent 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? a. Collecting semen b. Performing the pelvic examination c. Obtaining consent for examination d. Supporting the client's emotional status - ANSWER d. Supporting the client's emotional status The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present. A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following? a. Ear lobe and then to the xiphoid process b. Chin and then to the xiphoid process c. Ear lobe and then to the umbilicus d. Chin and then to the umbilicus - ANSWER a. Ear lobe and then to the xiphoid process The nurse measures the tube from the bridge of the nose to the xiphoid process to ensure that the tube reaches the stomach on insertion. The nurse educator is providing orientation to a group of nurses newly hired to an intensive care unit. The group of nurses are correct in stating which is the most common type of shock managed in critical care? a. Anaphylactic b. Hypovolemic c. Neurogenic d. Cardiogenic - ANSWER b. Hypovolemic During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some clients never fully recover from rape trauma. A client is being cared for in the ED. The client is assigned to the triage category of "urgent." How often must the nurse reassess the client? a. Every 15 minutes b. Every 30 minutes c. Every 60 minutes d. Every 120 minutes - ANSWER b. Every 30 minutes Clients assigned to the resuscitation category must receive continuous nursing surveillance, those in the emergent category must be reassessed at least every 15 minutes, clients in the urgent category must be reassessed at least every 30 minutes, those in the less urgent category must be reassessed at least every 60 minutes, and those in the nonurgent category must be reassessed at least every 120 minutes. The nurse is providing care to a client who will be ambulating for the first time after being extubated. The client tells the nurse, "I don't want to do this today. It's too soon and I am afraid I am not strong enough." What intervention should the nurse implement first for the client's fear of falling? a. Explore possible causes of the client's fear b. Evaluate the client for cognitive impairment c. Allow the client to remain on bedrest d. Clear the area around the bed - ANSWER a. Explore possible causes of the client's fear The client is exhibiting a fear of falling. For a client who has not mobilized in days due to mechanical ventilation and other medication interventions in the intensive care unit (ICU), ICU-acquired weakness is a reality. The client's concerns should be addressed by exploring the possible reasons for the fear of falling first. The client may be experiencing pain, dizziness or self-doubt. By identifying this cause, the nurse will be able to formulate the next action. The risk for falls is not due to cognitive impairment. This is evident in that the client is aware of current limitations and as a result is fearful. Preventative and rehabilitative measures to counter ICU-acquired weakness generally include early identification and treatment of potential causes of multiple organ failure (in particular severe sepsis and septic shock), avoiding unnecessary deep sedation and hyperglycemia, promotion of early mobilization, and thoughtful decisions regarding the risks versus benefits of corticosteroids. For these reasons, the client should not be encouraged to continue to have bedrest. Although the nurse should ensure the area around the bed is free of clutter to prevent a fall, this does not address the client's anxiety related to the fear of falling. The intensive care unit nurse is assessing a client who is going to require a peripheral intravenous (PIV) line for fluids. The nurse should consider what information in the client's health history when deciding the site for the PIV? a. The client has had a mastectomy on the right side b. The client has hypertension c. The client has a fluid volume restriction d. The client has a history of falls - ANSWER a. The client has had a mastectomy on the right side Contraindications to the placement of a PIV line in any specific placement (right vs. left side) will include history of mastectomy, arterial-venous shunt placement, peripherally inserted central catheter (PICC) line placement, thrombus, trauma, and other device placements, such as splints and casts. The nurse will only have the option to start the PIV on a site in the client's left arm if the client has had a ride-sided mastectomy. A history of hypertension does not preclude the client from having a PIV inserted in any specific location. Although fluid requirements are monitored more strictly with clients who are on a fluid volume restriction, this does not influence the placement of the PIV. The nurse should always be aware of the risks of a PIV for a client with a falls history. The tubing can be a tripping hazard, therefore, the client with a falls history who requires a PIV should be closely monitored but this does not preclude the client from having a PIV inserted. Which solid organ is most frequently injured in a penetrating trauma? a. Lung b. Liver c. Pancreas