Nokea
A provider prescribes diazepam (Valium) to a client who was bitten by a black widow spider. The client asks, 'What is this medication for?' How should the nurse respond?
- A. This medication is an antivenom for this type of bite.
- B. It is to relieve muscle rigidity and spasms.
- C. It prevents respiratory difficulty from excessive secretions.
- D. This medication will prevent respiratory failure.
Correct Answer: B
Rationale: Black widow spider venom causes latrodectism, characterized by muscle rigidity and spasms. Diazepam, a muscle relaxant, relieves these symptoms. It is not an antivenom, nor does it directly prevent respiratory issues.
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A nurse teaches a community class about ways to decrease the risk of lightning injuries. Which instructions should the nurse include? (Select all that apply.)
- A. Seek shelter in a building or enclosed vehicle.
- B. Hide under a tall tree.
- C. Do not take a bath or shower.
- D. Turn off the television.
- E. Remove all body piercings.
- F. Put down golf clubs or gardening tools.
Correct Answer: A,C,D,F
Rationale: Seeking shelter, avoiding water, turning off electronics, and putting down conductive tools reduce lightning injury risk. Hiding under a tall tree increases risk, and body piercings do not significantly affect lightning strike likelihood.
An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement?
- A. Administer dexamethasone (Decadron).
- B. Complete a mental status examination.
- C. Request the client for computed tomography of the brain.
- D. Request a psychiatric consult.
Correct Answer: A
Rationale: The client is exhibiting signs of mountain sickness and high altitude cerebral edema (HACE). Dexamethasone reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not treat mountain sickness or HACE.
A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.)
- A. Wear synthetic clothing instead of cotton to keep your skin dry.
- B. Drink plenty of fluids. Brandy can be used to keep your body warm.
- C. Remove your hat when exercising to prevent the loss of heat.
- D. Layer clothing to trap heat effectively.
- E. Know your physical limits. Come in out of the cold when limits are reached.
Correct Answer: A,D,E
Rationale: Synthetic clothing wicks moisture, layering traps heat, and knowing physical limits prevents overexposure. Alcohol like brandy causes heat loss, and removing a hat during exercise increases heat loss, both of which are incorrect.
An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include? (Select all that apply.)
- A. Administer oxygen via mask or nasal cannula.
- B. Administer ibuprofen, an antipyretic medication.
- C. Apply cooling techniques until core body temperature is less than 101°F.
- D. Infuse 0.9% sodium chloride via a large-bore intravenous cannula.
- E. Obtain baseline serum electrolytes and cardiac enzymes.
Correct Answer: A,D,E
Rationale: Heat stroke requires oxygen therapy, IV fluids, and baseline lab tests. Cooling should continue until the core temperature is around 102°F, not 101°F. Antipyretics like ibuprofen are ineffective for heat stroke.
A provider prescribes Crotalidae Polyvalent Immune Fab (CroFab) for a client who is admitted after being bitten by a pit viper snake. Which assessment should the nurse complete prior to administering this medication?
- A. Inspect the temperature for signs of fever.
- B. Check the client's creatine kinase level.
- C. Ask about allergies to pineapple or papaya.
- D. Inspect the skin for signs of internal hives.
Correct Answer: C
Rationale: CroFab is an antivenom for pit viper bites. Assessing for allergies to pineapple or papaya (due to bromelain and papain components) is critical to prevent hypersensitivity reactions. Other assessments are relevant but not the priority before administration.