Nokea
A patient is brought to the ED by two police officers. The patient was found unconscious on the sidewalk, with his face and hands covered in blood. At present, the patient is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the patient in restraints. What action should the nurse perform when the patient is restrained?
- A. Frequently assess the patient's skin integrity.
- B. Inform the patient that he is likely to be charged with assault.
- C. Avoid interacting with the patient until the restraints are removed.
- D. Take the opportunity to perform a full physical assessment.
Correct Answer: A
Rationale: Frequent skin integrity checks prevent injury from restraints. Legal charges are not the nurse's role, interaction should continue, and a full assessment may be unsafe while combative.
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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.
A patient is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the patient's cardiopulmonary status, the nurse should prepare to perform what intervention?
- A. Administer a bolus of lactated Ringer's.
- B. Administer naloxone hydrochloride (Narcan).
- C. Insert an indwelling urinary catheter.
- D. Perform a focused neurologic assessment.
Correct Answer: B
Rationale: Naloxone reverses opioid overdose effects like respiratory depression. Fluid boluses, catheterization, or neurologic assessments are secondary after stabilization.
A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding?
- A. Absence of bruising at contusion sites
- B. Rapid pulse and decreased capillary refill
- C. Increased BP with narrowed pulse pressure
- D. Sudden diaphoresis
Correct Answer: B
Rationale: Rapid pulse and poor capillary refill suggest hypovolemia from internal hemorrhage. Increased BP or diaphoresis alone are less specific, and bruising absence doesn't rule it out.
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 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.