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A patient has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the patient's bladder is distended. What is the nurse's most appropriate action?
- A. Withhold fluids from the patient.
- B. Perform intermittent urinary insertionization before.
- C. Insert a narrow-gauge indwelling in the urinary catheter.
- D. D) Await orders following the urologist's assessment.
Correct Answer: D
Rationale: Await orders following the urologist's assessment. Urethral injury may contraindicate catheterization, so urologic consultation is needed first. Withholding fluids is secondary.
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A patient is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply.
- A. Ascites
- B. Rebound tenderness
- C. Changes in bowel sounds
- D. Muscular rigidity
- E. Copious diarrhea
Correct Answer: B,C,D
Rationale: Rebound tenderness, altered bowel sounds, and muscular rigidity indicate peritoneal irritation. Ascites and diarrhea are not specific to this condition.
The nurse observes that the family members of a patient who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family?
- A. Anxiety and denial
- B. Remorse and guilt
- C. Anger
- D. Grief
Correct Answer: B
Rationale: The family's blame and sense of responsibility indicate remorse and guilt, a stage of crisis where individuals process feelings of fault. This is distinct from anxiety, anger, or grief.
An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patient's acuity as well as what other variable?
- A. The likelihood of a repeat visit to the ED in the next 7 days
- B. The resources that the patient is likely to require
- C. The patient's or insurer's ability to pay for care
- D. Whether the patient is known to ED staff from previous visits
Correct Answer: B
Rationale: ESI triage considers acuity and anticipated resource needs, such as diagnostics or consultations. Repeat visits, payment ability, or prior ED history are not triage factors.
The nurse is caring for a patient admitted with a drug overdose. What is the nurse's priority responsibility in caring for this patient?
- A. Support the patient's respiratory and cardiovascular function.
- B. Provide for the safety of the patient.
- C. Enhance clearance of the offending agent.
- D. Ensure the safety of the staff.
Correct Answer: A
Rationale: Supporting respiratory and cardiovascular function is the priority in drug overdose to sustain life. Safety and agent clearance are important but secondary.
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.