Chapter 72: Emergency Nursing Verified Instructor Notes for Exam Preparation

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