Nokea
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.
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A 23-year-old woman is brought to the ED complaining of stomach cramps, nausea, vomiting, and diarrhea. The care team suspects food poisoning. What is the key to treatment in food poisoning?
- A. Administering IV antibiotics
- B. Assessing immunization status
- C. Determining the source and type of food poisoning
- D. Determining if anyone else in the family is ill
Correct Answer: C
Rationale: Identifying the source and type of food poisoning guides specific treatment, such as fluid replacement or antitoxins. Antibiotics are rarely needed, and immunization or family illness are secondary.
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 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.
A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patient's peritoneum, the nurse should anticipate what diagnostic test?
- A. Radiograph
- B. Computed tomography (CT) scan
- C. Complete blood count (CBC)
- D. Barium swallow
Correct Answer: B
Rationale: CT scans effectively detect intraperitoneal injuries from blunt trauma. Radiographs are less detailed, CBC indicates blood loss but not location, and barium swallow is irrelevant.
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.