Nokea
The ED nurse is caring for a female client with a greenstick fracture of the left forearm and multiple contusions on the face, arms, trunk, and legs. The significant other is in the treatment area with the client. Which nursing interventions should the nurse implement? List in order of priority.
- A. Determine if the client has a plan for safety.
- B. Assess the pulse, temperature, and capillary refill of the left wrist and hand.
- C. Ask the client if she feels safe in her own home.
- D. Request the significant other wait in the waiting room during the examination.
- E. Notify the social worker to consult on the case.
Correct Answer: D,C,A,B,E
Rationale: 1) Request significant other to wait (ensures private assessment); 2) Ask about safety (screens for abuse); 3) Plan for safety (addresses immediate risk); 4) Assess limb (ensures circulation); 5) Notify social worker (coordinates support).
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The client presents to the ED with acute vomiting after eating at a fast-food restaurant. There has not been any diarrhea. The nurse suspects botulism poisoning. Which nursing problem is the highest priority for this client?
- A. Fluid volume loss.
- B. Risk for respiratory paralysis.
- C. Abdominal pain.
- D. Anxiety.
Correct Answer: B
Rationale: Botulism causes progressive paralysis, including respiratory muscles, making respiratory paralysis the highest priority. Fluid loss, pain, and anxiety are secondary.
The client who was abused as a child is diagnosed with post-traumatic stress disorder (PTSD). Which intervention should the nurse implement when the client is resting?
- A. Call the client’s name to awaken him or her, but don’t touch the client.
- B. Touch the client gently to let him or her know you are in the room.
- C. Enter the room as quietly as possible to not disturb the client.
- D. Do not allow the client to be awakened at all when sleeping.
Correct Answer: A
Rationale: Calling the name without touching avoids startling a PTSD client, preventing flashbacks. Touching, quiet entry, or preventing awakening may trigger or disrupt.
The nurse is discharging a client from the ED with a sutured laceration on the right knee. Which information is most important for the nurse to obtain?
- A. The date of the client’s last tetanus injection.
- B. The name of the client’s regular health-care provider.
- C. Explain the sutures must be removed in 10 to 14 days.
- D. Determine if the client has any drug or food allergies.
Correct Answer: A
Rationale: Tetanus status is critical for lacerations to prevent infection, especially if >5 years since last dose. HCP name, suture removal, and allergies are secondary.
The nurse is caring for a client in the ED with abdominal trauma who has had peritoneal lavage. Which intervention should the nurse include in the plan of care?
- A. Assess for the presence of blood, bile, or feces.
- B. Palpate the client for bilateral femoral pulses.
- C. Perform Leopold’s maneuver every eight (8) hours.
- D. Collect information on the client’s dietary history.
Correct Answer: A
Rationale: Peritoneal lavage detects blood, bile, or feces, indicating internal injury. Femoral pulses, Leopold’s maneuver (pregnancy), and diet history are irrelevant.
The nurse working in the emergency department is admitting a 34-year-old female client for one of multiple admissions for spousal abuse. The client has refused to leave her husband or to press charges against him. Which action should the nurse implement?
- A. Insist the woman press charges this time.
- B. Treat the wounds and do nothing else.
- C. Tell the woman her husband could kill her.
- D. Give the woman the number of a women’s shelter.
Correct Answer: D
Rationale: Providing a women’s shelter number empowers the client with resources without coercion. Insisting on charges, minimal treatment, or fear tactics disrespect autonomy.