Nokea
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.
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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 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 who has been diagnosed with cholecystitis is being discharged home from the ED to be scheduled for surgery later. The patient received morphine during the present ED admission and is visibly drowsy. When providing health education to the patient, what would be the most appropriate nursing action?
- A. Give written instructions to patient.
- B. Give verbal instructions to one of the patient's family members.
- C. Telephone the patient the next day with verbal instructions.
- D. Give verbal and written instructions to patient and a family member.
Correct Answer: D
Rationale: Verbal and written instructions to both the patient and family ensure comprehension despite drowsiness. Written instructions alone or delayed calls risk misunderstanding.
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 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.