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A patient who attempted suicide being treated in the ED is accompanied by his mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following action?
- A. Refer the family to psychiatry in order to provide them with support.
- B. Explore the causes of the patient's suicide attempt with the family.
- C. Encourage the family to participate in the bedside care of the patient.
- D. Ensure that the family receives appropriate crisis intervention services.
Correct Answer: D
Rationale: Crisis intervention services support the family after a suicide attempt. Exploring causes is insensitive, bedside care is impractical, and psychiatry isn't the primary support source.
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The ED nurse is planning the care of a patient who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal?
- A. Encouraging the patient to gain a sense of control over his or her life
- B. Collecting sufficient evidence to secure a criminal conviction
- C. Helping the patient understand that this will not happen again
- D. Encouraging the patient to verbalize what happened during the assault
Correct Answer: A
Rationale: Nursing interventions post-sexual assault focus on empowering the patient to regain control, prioritizing emotional recovery over legal outcomes, future safety guarantees, or forced verbalization.
The ED nurse admitting a patient with a history of depression is screening the patient for suicide risk. What assessment question should the nurse ask when screening the patient?
- A. How would you describe your mood over the past few days?
- B. Have you ever thought about taking your own life?
- C. How do you think that your life is most likely to end?
- D. How would you rate the severity of your depression right now on a 10-point scale?
Correct Answer: B
Rationale: Directly asking about suicidal thoughts is essential for risk assessment in depression. Mood, life expectancy, or severity ratings are less specific for suicide screening.
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.
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.
An 83-year-old patient is brought in by ambulance from a long-term care facility. The patient's symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage. Why would this be true?
- A. Older adults may have an altered response to treatment.
- B. Older adults are often reluctant to adhere to prescribed treatment.
- C. Older adults have difficulty giving a health history.
- D. Older adults often stigmatize their peers who use the ED.
Correct Answer: A
Rationale: Older adults may have atypical presentations or altered treatment responses, complicating emergency management. Nonadherence, history difficulties, or stigmatization are not primary issues.