Nokea
A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what?
- A. Liver
- B. Small bowel
- C. Stomach
- D. Large bowel
Correct Answer: B
Rationale: Penetrating abdominal injuries, like gunshot wounds, frequently damage hollow organs, with the small bowel being most common due to its large surface area. The liver is a solid organ.
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The triage nurse is working in an ED. A homeless person is admitted during a blizzard with complaints, being unable to reach his feet and lower legs. Core temperature is noted at 33.2°C (91.8°F). The patient is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage priority for the nurse in the care of this patient?
- A. Addressing the patient
- B. Addressing hypothermia for the patient's frostbite in his lower extremities
- C. Addressing the patient's alcohol intoxication
- D. Addressing malnutrition in the patient
Correct Answer: A
Rationale: A) Addressing hypothermia is the priority. Hypothermia is a systemic, life-threatening condition requiring immediate treatment, while frostbite, intoxication, and alcohol abuse are less acute.
A patient is brought to the ER in an unconscious state. The physician notes that the patient is in need of emergency surgery. No family members are present, and the patient does not have identification. What action by the nurse is most important regarding consent for treatment?
- A. Ask the social worker to come and sign the consent.
- B. Contact the police to obtain the patient's identity.
- C. Obtain a court order to treat the patient.
- D. Clearly document LOC and health status on the patient's chart.
Correct Answer: D
Rationale: Documenting the patient's unconscious state and critical condition justifies emergency treatment without consent. Social workers can't sign, police contact delays care, and court orders are too slow.
A triage nurse is talking to a patient when the patient begins choking on his lunch. The patient is coughing forcefully. What should the nurse do?
- A. Stand him up and perform the abdominal thrust maneuver from behind.
- B. Lay him down, straddle him, and perform the abdominal thrust maneuver.
- C. Leave him to get assistance.
- D. Stay with him and encourage him, but not intervene at this time.
Correct Answer: D
Rationale: A forcefully coughing patient may dislodge the obstruction, so the nurse should stay and encourage without intervening unless obstruction worsens. Abdominal thrusts are for complete obstruction.
A nurse is caring for a patient who has been the victim of sexual assault. The nurse documents that the patient appears to be in a state of shock, verbalizing fear, guilt, and humiliation. What phase of rape trauma syndrome is this patient most likely experiencing?
- A. Reorganization phase
- B. Denial phase
- C. Heightened anxiety phase
- D. Acute disorganization phase
Correct Answer: D
Rationale: The acute disorganization phase of rape trauma syndrome involves shock, fear, guilt, and humiliation. Denial, heightened anxiety, and reorganization occur in different stages.
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.