Nokea
A nurse teaches a community class about ways to decrease the risk of lightning injuries. Which instructions should the nurse include? (Select all that apply.)
- A. Seek shelter in a building or enclosed vehicle.
- B. Hide under a tall tree.
- C. Do not take a bath or shower.
- D. Turn off the television.
- E. Remove all body piercings.
- F. Put down golf clubs or gardening tools.
Correct Answer: A,C,D,F
Rationale: Seeking shelter, avoiding water, turning off electronics, and putting down conductive tools reduce lightning injury risk. Hiding under a tall tree increases risk, and body piercings do not significantly affect lightning strike likelihood.
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A provider prescribes diazepam (Valium) to a client who was bitten by a black widow spider. The client asks, 'What is this medication for?' How should the nurse respond?
- A. This medication is an antivenom for this type of bite.
- B. It is to relieve muscle rigidity and spasms.
- C. It prevents respiratory difficulty from excessive secretions.
- D. This medication will prevent respiratory failure.
Correct Answer: B
Rationale: Black widow spider venom causes latrodectism, characterized by muscle rigidity and spasms. Diazepam, a muscle relaxant, relieves these symptoms. It is not an antivenom, nor does it directly prevent respiratory issues.
An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first?
- A. Electrocardiogram (ECG)
- B. Electroencephalogram (EEG)
- C. Creatine kinase
- D. Computed tomography of head
Correct Answer: A
Rationale: Clients who survive a lightning strike can have serious myocardial injury. An ECG is the priority to assess for cardiac complications. Other assessments should be completed but are not the priority.
A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed?
- A. I can go swimming all by myself because I am a certified lifeguard.
- B. I will not leave my toddler alone in the bathtub for even a minute.
- C. I will appoint an adult to supervise the pool at all times during a party.
- D. I will make sure that there is a phone near my pool in case of an emergency.
Correct Answer: A
Rationale: People should never swim alone, regardless of lifeguard status, due to the risk of drowning. The other statements indicate good understanding of water safety principles.
An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement?
- A. Administer dexamethasone (Decadron).
- B. Complete a mental status examination.
- C. Request the client for computed tomography of the brain.
- D. Request a psychiatric consult.
Correct Answer: A
Rationale: The client is exhibiting signs of mountain sickness and high altitude cerebral edema (HACE). Dexamethasone reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not treat mountain sickness or HACE.
On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 100.1°F, pulse 120 beats/min, respirations 20 breaths/min, blood pressure 100/66 mm Hg. Which action should the nurse take?
- A. Encourage the client to drink cool water or sports drinks.
- B. Start an intravenous line and infuse normal saline.
- C. Apply cooling blankets.
- D. Administer acetaminophen.
Correct Answer: B
Rationale: The client is showing signs of heat exhaustion, characterized by confusion, elevated temperature, and low blood pressure. Starting an IV and infusing normal saline is critical to restore hydration and stabilize blood pressure. Encouraging oral fluids may not be sufficient for a confused patient, cooling blankets are more appropriate for heat stroke, and acetaminophen does not address the underlying dehydration.