Nokea
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.
You may also like to solve these questions
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
- D. Cheyne-Stokes respirations
Correct Answer: B
Rationale: Heat stroke is characterized by anhidrosis (lack of sweating), hot dry skin, and hyperthermia. It causes hypotension, not hypertension, and is not linked to diuresis or Cheyne-Stokes breathing.
A patient with multiple trauma is brought to the ED by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this patient's care?
- A. Intubating the patient
- B. Notifying family members
- C. Ensuring IV access
- D. Delivering specimens to the laboratory
Correct Answer: C
Rationale: Ensuring IV access is a key ED nursing role for administering fluids or medications. Intubation is for specialized providers, family notification is not a nurse's role, and specimen delivery is handled by others.
A patient with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the patient's injuries?
- A. Myocardial infarction
- B. Hypoglycemia
- C. Hemorrhage
- D. Peritonitis
Correct Answer: C
Rationale: Cool, moist skin, tachycardia, and hypotension suggest hemorrhage, a common complication of femur fractures due to significant blood loss. MI, hypoglycemia, and peritonitis are less likely.
A patient is being treated for bites that she suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action?
- A. Apply a dressing saturated with chlorhexidine.
- B. Wash the bites with soap and water.
- C. Arrange for the patient to receive a hepatitis B vaccination.
- D. Assess the patient's immunization history.
Correct Answer: B
Rationale: Washing bites with soap and water after forensic documentation prevents infection. Chlorhexidine dressings, hepatitis B vaccination, or immunization history are not immediate priorities.
A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient?
- A. Assessing the patient's oral temperature frequently
- B. Ensuring continuous ECG monitoring
- C. Massaging the patient's skin surfaces to promote circulation
- D. Administering bronchodilators by nebulizer
Correct Answer: B
Rationale: Continuous ECG monitoring is essential during hypothermia rewarming to detect arrhythmias. Oral temperatures are unreliable, massage risks tissue damage, and bronchodilators are not indicated.