Nokea
The client presents to the ED with acute vomiting after eating at a fast-food restaurant. There has not been any diarrhea. The nurse suspects botulism poisoning. Which nursing problem is the highest priority for this client?
- A. Fluid volume loss.
- B. Risk for respiratory paralysis.
- C. Abdominal pain.
- D. Anxiety.
Correct Answer: B
Rationale: Botulism causes progressive paralysis, including respiratory muscles, making respiratory paralysis the highest priority. Fluid loss, pain, and anxiety are secondary.
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The client who was abused as a child is diagnosed with post-traumatic stress disorder (PTSD). Which intervention should the nurse implement when the client is resting?
- A. Call the client’s name to awaken him or her, but don’t touch the client.
- B. Touch the client gently to let him or her know you are in the room.
- C. Enter the room as quietly as possible to not disturb the client.
- D. Do not allow the client to be awakened at all when sleeping.
Correct Answer: A
Rationale: Calling the name without touching avoids startling a PTSD client, preventing flashbacks. Touching, quiet entry, or preventing awakening may trigger or disrupt.
The nurse working in the emergency department is admitting a 34-year-old female client for one of multiple admissions for spousal abuse. The client has refused to leave her husband or to press charges against him. Which action should the nurse implement?
- A. Insist the woman press charges this time.
- B. Treat the wounds and do nothing else.
- C. Tell the woman her husband could kill her.
- D. Give the woman the number of a women’s shelter.
Correct Answer: D
Rationale: Providing a women’s shelter number empowers the client with resources without coercion. Insisting on charges, minimal treatment, or fear tactics disrespect autonomy.
The nurse is responding to a disaster call from home following a multivehicle motor-vehicle accident. Which action should the nurse take first?
- A. Go to the emergency department to triage the clients coming in.
- B. Assist the charge nurse to identify clients who could be discharged.
- C. Report to the command center for assignment.
- D. Pack a bag to be able to stay until the emergency is over.
Correct Answer: C
Rationale: Reporting to the command center ensures coordinated assignment per disaster protocol. Triaging, discharging, or packing are secondary.
The parents bring their toddler to the ED in a panic. The parents state the child had been playing in the kitchen and got into some cleaning agents and swallowed an unknown quantity of the agents. Which health-care agency should the nurse contact at this time?
- A. Child Protective Services (CPS).
- B. The local police department.
- C. The Department of Health.
- D. The Poison Control Center.
Correct Answer: D
Rationale: The Poison Control Center provides immediate guidance on ingested toxins, critical for treatment. CPS, police, and health departments are secondary.
The ED nurse is caring for a female client with a greenstick fracture of the left forearm and multiple contusions on the face, arms, trunk, and legs. The significant other is in the treatment area with the client. Which nursing interventions should the nurse implement? List in order of priority.
- A. Determine if the client has a plan for safety.
- B. Assess the pulse, temperature, and capillary refill of the left wrist and hand.
- C. Ask the client if she feels safe in her own home.
- D. Request the significant other wait in the waiting room during the examination.
- E. Notify the social worker to consult on the case.
Correct Answer: D,C,A,B,E
Rationale: 1) Request significant other to wait (ensures private assessment); 2) Ask about safety (screens for abuse); 3) Plan for safety (addresses immediate risk); 4) Assess limb (ensures circulation); 5) Notify social worker (coordinates support).