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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.
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The ED nurse is caring for a client who had a severe allergic reaction to a bee sting. Which discharge instructions should the nurse discuss with the client?
- A. Instruct the client to wear a medical identification bracelet.
- B. Apply corticosteroid cream to the site to prevent anaphylaxis.
- C. Administer epinephrine 1:10,000 intravenously every three (3) minutes.
- D. Teach the client to avoid attracting insects by wearing bright colors.
Correct Answer: A
Rationale: A medical ID bracelet alerts others to the allergy, critical for future emergencies. Topical steroids don’t prevent anaphylaxis, IV epinephrine is hospital-based, and bright colors attract insects.
The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect?
- A. Cardiogenic shock.
- B. Hypovolemic shock.
- C. Neurogenic shock.
- D. Septic shock.
Correct Answer: B
Rationale: NSAID-induced gastrointestinal bleeding can cause hypovolemic shock, indicated by tachycardia, hypotension, and pale, clammy skin. Cardiogenic involves cardiac failure, neurogenic involves bradycardia, and septic involves fever.
The nurse is teaching the client home care instructions for a reimplanted finger after a traumatic amputation. Which information should the nurse include in the teaching?
- A. Perform range-of-motion exercises weekly.
- B. Smoking may be resumed if it does not cause nausea.
- C. Protect the finger and be careful not to reinjure the finger.
- D. An elevated temperature is the only reason to call the HCP.
Correct Answer: C
Rationale: Protecting the reimplanted finger prevents reinjury, critical for healing. ROM timing varies, smoking impairs circulation, and multiple symptoms warrant HCP contact.
The ED receives a client involved in a motor-vehicle accident. The nurse notes a large hematoma on the right flank. Which intervention should the nurse implement first?
- A. Insert an indwelling urinary catheter.
- B. Take the vital signs every 15 minutes.
- C. Monitor the skin turgor every hour.
- D. Mark the edges of the bruised area.
Correct Answer: B
Rationale: Frequent vital signs assess for hypovolemia from potential internal bleeding (flank hematoma suggests renal or retroperitoneal injury). Catheter, skin turgor, and marking are secondary.
Which equipment must be immediately brought to the client’s bedside when a code is called for a client who has experienced a cardiac arrest?
- A. A ventilator.
- B. A crash cart.
- C. A gurney.
- D. Portable oxygen.
Correct Answer: B
Rationale: A crash cart contains defibrillator, medications, and airway equipment, essential for cardiac arrest. Ventilator, gurney, and oxygen are secondary or supportive.