Nokea
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.
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A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed?
- A. I can go swimming all by myself because I am a certified lifeguard.
- B. I will not leave my toddler alone in the bathtub for even a minute.
- C. I will appoint an adult to supervise the pool at all times during a party.
- D. I will make sure that there is a phone near my pool in case of an emergency.
Correct Answer: A
Rationale: People should never swim alone, regardless of lifeguard status, due to the risk of drowning. The other statements indicate good understanding of water safety principles.
A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this client's teaching? (Select all that apply.)
- A. Consult an exterminator to control bugs in and around your home.
- B. Wear synthetic clothing that dries quickly.
- C. Use insect repellent with DEET.
- D. Wear long sleeves and pants in wooded areas.
- E. Avoid wearing bright colors or strong perfumes.
Correct Answer: A,C,D,E
Rationale: Consulting an exterminator, using DEET repellent, wearing protective clothing, and avoiding attractants like bright colors or perfumes reduce bug bite risk. Synthetic clothing drying quickly is not directly relevant to preventing bites.
A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment?
- A. Administer intravenous morphine.
- B. Wrap the limb with a compression dressing.
- C. Massage the frostbitten areas.
- D. Assess the limb for compartment syndrome.
Correct Answer: A
Rationale: Rapid rewarming in a water bath is recommended for frostbite, but it causes severe pain. Administering IV morphine prior to treatment is essential for pain management. Wrapping with a compression dressing or massaging the area can cause further tissue damage, and assessing for compartment syndrome is not the priority before rewarming.
A nurse plans care for a client admitted with a snakebite on the right leg. With whom should the nurse collaborate?
- A. The facility's neurologist
- B. The regional poison control center
- C. The physical therapy department
- D. A herpetologist (snake specialist)
Correct Answer: B
Rationale: For snakebites, the regional poison control center provides specialized advice on antivenom and client management. Neurologists, physical therapists, or herpetologists are not the primary resources for acute snakebite care.
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.