Nokea
A patient who is unconscious after a fall from a ladder is transported to the emergency department by family members. During the primary survey of the patient, which of the following actions should the nurse implement?
- A. Assess the patient's vital signs
- B. Attach a cardiac electrocardiogram (ECG) monitor
- C. Obtain a Glasgow Coma Scale score
- D. Ask about chronic medical conditions
Correct Answer: C
Rationale: The Glasgow Coma Scale score assesses neurological disability during the primary survey, prioritizing evaluation of consciousness in an unconscious trauma patient. Vital signs and medical history are part of the secondary survey.
You may also like to solve these questions
The nurse is preparing to rewarm a patient with hypothermia. Which of the following actions should the nurse implement?
- A. Attach a cardiac monitor
- B. Insert a urinary catheter
- C. Assist with endotracheal intubation
- D. Prepare sympathomimetic drugs for emergency administration
Correct Answer: A
Rationale: Rewarming can cause dysrhythmias in hypothermic patients, so cardiac monitoring is essential to detect and treat these complications. Urinary catheterization and intubation are not routinely required, and sympathomimetics increase dysrhythmia risk.
The nurse is caring for a patient who has sustained a black widow spider bite. When would the nurse expect the symptoms to peak?
- A. 30 minutes
- B. 2-3 hours
- C. 5-6 hours
- D. 9-10 hours
Correct Answer: B
Rationale: Symptoms of a black widow spider bite, caused by neurotoxic venom, typically peak within 2-3 hours as the venom affects the nervous system, causing muscle cramps and pain.
The nurse is admitting a patient to the emergency department after a submersion injury. Which of the following assessments is priority?
- A. Apical pulse
- B. Lung sounds
- C. Body temperature
- D. Level of consciousness
Correct Answer: B
Rationale: Lung sounds are the priority assessment after a submersion injury to evaluate for pulmonary edema or aspiration, which can compromise oxygenation. Other assessments like pulse, temperature, and consciousness are important but secondary to ensuring adequate ventilation.
These four patients arrive in the emergency department after a motor vehicle crash. In which order should they be assessed?
- A. A 72-year-old with palpitations and chest pain
- B. A 45-year-old complaining of 6/10 abdominal pain
- C. A 22-year-old with multiple fractures of the face and jaw
- D. A 30-year-old with a misaligned right leg with intact pulses
Correct Answer: C,A,B,D
Rationale: The 22-year-old with facial and jaw fractures is assessed first due to potential airway compromise. The 72-year-old with chest pain (possible cardiac ischemia) is next, followed by the 45-year-old with abdominal pain (potential internal bleeding). The 30-year-old with a leg fracture and intact pulses is least urgent.
The nurse is rewarming a patient who arrived in the emergency department (ED) with a temperature of 29°C (84.2°F) and no audible heart sounds. Which of the following temperatures should the nurse rewarm the patient to, prior to a pronouncement of death?
- A. 30°C (86.0°F)
- B. 32°C (89.6°F)
- C. 34°C (93.2°F)
- D. 36°C (96.8°F)
Correct Answer: B
Rationale: Patients with severe hypothermia must be rewarmed to at least 32°C (89.6°F) before pronouncing death, as hypothermia can mimic death by suppressing vital signs, and ventricular fibrillation is a common cause of apparent death.