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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.
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A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action?
- A. Check the patient's blood glucose level.
- B. Assess for a documented history of major depression.
- C. Determine whether the patient has ingested a corrosive substance.
- D. Arrange for assessment of serum potassium levels.
Correct Answer: A
Rationale: Hypoglycemia can mimic alcohol intoxication symptoms like confusion and slurred speech, so checking blood glucose is critical. Depression, corrosive ingestion, or potassium levels are less likely mimics.
A patient with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the patient's injuries?
- A. Myocardial infarction
- B. Hypoglycemia
- C. Hemorrhage
- D. Peritonitis
Correct Answer: C
Rationale: Cool, moist skin, tachycardia, and hypotension suggest hemorrhage, a common complication of femur fractures due to significant blood loss. MI, hypoglycemia, and peritonitis are less likely.
You are a floor nurse caring for a patient with alcohol withdrawal syndrome. What would be an appropriate nursing action to minimize the potential for hallucinations?
- A. Engage the patient in a process of health education.
- B. Administer opioid analgesics as ordered.
- C. Place the patient in a private, well-lit room.
- D. Provide television or a radio as therapeutic distraction
Correct Answer: C
Rationale: A quiet, well-lit private room reduces sensory overload, minimizing hallucinations in alcohol withdrawal. Analgesics or media may worsen symptoms, and education is inappropriate during acute withdrawal.
A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient?
- A. Assessing the patient's oral temperature frequently
- B. Ensuring continuous ECG monitoring
- C. Massaging the patient's skin surfaces to promote circulation
- D. Administering bronchodilators by nebulizer
Correct Answer: B
Rationale: Continuous ECG monitoring is essential during hypothermia rewarming to detect arrhythmias. Oral temperatures are unreliable, massage risks tissue damage, and bronchodilators are not indicated.
The nurse observes that the family members of a patient who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family?
- A. Anxiety and denial
- B. Remorse and guilt
- C. Anger
- D. Grief
Correct Answer: B
Rationale: The family's blame and sense of responsibility indicate remorse and guilt, a stage of crisis where individuals process feelings of fault. This is distinct from anxiety, anger, or grief.