Nokea
The client is brought to the emergency department by the police for public disorderliness. The client reports feeling no pain and is unconcerned that the police have arrested him. The nurse notes the client has epistaxis and nasal congestion. Which substance should the nurse suspect the client has abused?
- A. Marijuana.
- B. Heroin.
- C. Ecstasy.
- D. Cocaine.
Correct Answer: D
Rationale: Cocaine (D) causes epistaxis, nasal congestion, and euphoria with pain insensitivity. Marijuana (A), heroin (B), and ecstasy (C) do not typically cause these nasal symptoms.
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The client is in status epilepticus. Which interventions, if prescribed, should be included in this client's immediate treatment? Select all that apply.
- A. Administer dexamethasone intravenously.
- B. Give oxygen and prepare for endotracheal intubation.
- C. Obtain a defibrillator and prepare to use it immediately.
- D. Remove nearby objects to protect the client from injury.
- E. Administer lorazepam intravenously STAT.
Correct Answer: B,D,E
Rationale: Anticonvulsant medications such as phenytoin (Dilantin), and not anti-inflammatory medications such as dexamethasone (Decadron), are administered IV to control seizure activity. Status epilepticus is a medical emergency. The client is at risk for brain hypoxia and permanent brain damage. The client needs additional oxygen, and intubation will secure the airway. Defibrillation is treatment for ventricular fibrillation, a lethal heart dysrhythmia. Care is taken to protect the client from injury during the seizure. Either lorazepam (Ativan) or diazepam (Valium) is administered initially to terminate the seizure because they can be administered more rapidly than phenytoin.
The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other?
- A. Awaken the client every two (2) hours.
- B. Monitor for increased intracranial pressure (ICP).
- C. Observe frequently for hypervigilance.
- D. Offer the client food every three (3) to four (4) hours.
Correct Answer: A
Rationale: For a mild concussion, monitoring for worsening neurological status is key. Awakening every 2 hours (A) allows assessment for altered consciousness. Monitoring ICP (B) is complex and not feasible at home, hypervigilance (C) is not typical, and frequent feeding (D) is unnecessary.
The nurse in a long-term care facility has noticed a change in the behavior of one of the clients. The client no longer participates in activities and prefers to stay in his room. Which intervention should the nurse implement first?
- A. Insist that the client go to the dining room for meals.
- B. Notify the family of the change in behavior.
- C. Determine if the client wants another roommate.
- D. Complete a Geriatric Depression Scale.
Correct Answer: D
Rationale: Social withdrawal may indicate depression. Completing a Geriatric Depression Scale (D) is the first step to assess this possibility. Forcing dining (A), notifying family (B), or changing roommates (C) are premature without assessment.
The male client is admitted to the emergency department following a motorcycle accident. The client was not wearing a helmet and struck his head on the pavement. The nurse identifies the concept as impaired intracranial regulation. Which interventions should the emergency department nurse implement in the first five (5) minutes? Select all that apply.
- A. Stabilize the client’s neck and spine.
- B. Contact the organ procurement organization to speak with the family.
- C. Elevate the head of the bed to 70 degrees.
- D. Perform a Glasgow Coma Scale assessment.
- E. Ensure the client has a patent peripheral venous catheter in place.
- F. Check the client’s driver’s license to see if he will accept blood.
Correct Answer: A,D,E
Rationale: Stabilizing the cervical spine (A) prevents spinal injury, Glasgow Coma Scale (D) assesses neurological status, and IV access (E) prepares for interventions. Organ procurement (B) is premature, high HOB (C) risks perfusion, and checking for blood acceptance (F) is secondary.
The client, who has a deteriorating status after having a stroke, has a rectal temperature of 102.3°F (39.1°C). Which should be the nurse’s rationale for initiating interventions to bring the temperature to a normal level?
- A. A normal temperature will strengthen the client’s immune system.
- B. A hypothermic state may increase the client’s chance of survival.
- C. A normal temperature will decrease the Glasgow Coma Scale score.
- D. Hyperthermia increases the likelihood of a larger area of brain infarct.
Correct Answer: D
Rationale: A normal temperature does not strengthen the immune system. Although hypothermia may increase the client’s chance for survival, the question is asking for the rationale for bringing the temperature to a normal level. Hyperthermia, not a normal temperature, is associated with lower scores on the Glasgow Coma Scale. The nurse should initiate temperature reduction measures because a temperature elevation in the client poststroke can cause an increase in the infarct size. This may be due to the increased oxygen demand with hyperthermia and peripheral vasodilation that decreases cerebral perfusion.