Nokea
A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding?
- A. Absence of bruising at contusion sites
- B. Rapid pulse and decreased capillary refill
- C. Increased BP with narrowed pulse pressure
- D. Sudden diaphoresis
Correct Answer: B
Rationale: Rapid pulse and poor capillary refill suggest hypovolemia from internal hemorrhage. Increased BP or diaphoresis alone are less specific, and bruising absence doesn't rule it out.
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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 patient's 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.
Correct Answer: A
Rationale: Respecting privacy minimizes trauma during a sexual assault assessment. Pubic hair is combed, not shaved; evidence goes in paper bags to avoid moisture; and bathing destroys evidence.
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
Correct Answer: B
Rationale: Screening for suicidal ideation is critical in depression to assess risk. Physical symptoms are relevant, interviews should be empathetic, and leaving the patient alone risks suicide.
A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply.
- A. Dysrhythmias
- B. Hypothermia
- C. Hypotension
- D. Hyperglycemia
- E. Delirium
Correct Answer: A,C,E
Rationale: Fluid and electrolyte imbalances from food poisoning cause dysrhythmias, hypotension, and delirium. Hypothermia and hyperglycemia are not typically associated.
A patient is brought to the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temperature of 40.1°C (104.2°F). What would be the priority nursing action for this patient?
- A. Monitor cardiovascular effects.
- B. Administer antipyretics.
- C. Ensure airway and ventilation.
- D. Prevent seizure activity.
Correct Answer: C
Rationale: Ensuring airway and ventilation is the priority in cocaine-induced hyperthermia, as respiratory compromise is life-threatening. Cardiovascular monitoring, antipyretics, and seizure prevention follow.
An obtunded patient is admitted to the ED after ingesting bleach. The nurse should prepare to assist with what intervention?
- A. Prompt administration of an antidote
- B. Gastric lavage
- C. Administration of activated charcoal
- D. Helping the patient drink large amounts of water
Correct Answer: D
Rationale: Diluting bleach ingestion with water is appropriate for corrosive substances. There's no antidote, lavage is contraindicated, and charcoal is ineffective for corrosives.