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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.
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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.
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.
A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the patient's frostbite?
- A. Immerse affected extremities in water slightly above normal body temperature.
- B. Immerse the patient's frostbitten extremities in the warmest water the patient can tolerate.
- C. Gently massage the patient's frozen extremities in between water baths.
- D. Perform passive range-of-motion exercises of the affected extremities to promote circulation.
Correct Answer: A
Rationale: Immersion in 37-40°C water safely rewarms frostbitten extremities. Hotter water risks burns, and massage or exercises cause further tissue damage.
A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply.
- A. Dysrhythmias
- B. Hypothermia
- C. Hypotension
- D. Hyperglycemia
- E. Delirium
Correct Answer: A,C,E
Rationale: Fluid and electrolyte imbalances from food poisoning cause dysrhythmias, hypotension, and delirium. Hypothermia and hyperglycemia are not typically associated.
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.