Nokea
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.
You may also like to solve these questions
The ED nurse is working triage. Which client should be triaged first?
- A. A client who has multiple injuries from a motor-vehicle accident.
- B. A client complaining of epigastric pain and nausea after eating.
- C. An elderly client who fell and fractured the left femoral neck.
- D. The client suffering from a migraine headache and nausea.
Correct Answer: A
Rationale: Multiple trauma from an MVA suggests life-threatening injuries, requiring immediate triage. Epigastric pain, fractures, and migraines are less urgent.
Which situation warrants the nurse obtaining information from a material safety data sheet (MSDS)?
- A. The custodian spilled a chemical solvent in the hallway.
- B. A visitor slipped and fell on the floor that had just been mopped.
- C. A bottle of antineoplastic agent broke on the client’s floor.
- D. The nurse was stuck with a contaminated needle in the client’s room.
Correct Answer: A
Rationale: MSDS provides handling and exposure information for chemical spills like solvents. Antineoplastic spills require specific protocols, and needle sticks or falls involve infection control or safety protocols, not MSDS.
The CPR instructor is discussing an automated external defibrillator (AED) during class. Which statement best describes an AED?
- A. It analyzes the rhythm and shocks the client in ventricular fibrillation.
- B. The client will be able to have synchronized cardioversion with the AED.
- C. It will keep the health-care provider informed of the client’s oxygen level.
- D. The AED will perform cardiac compressions on the client.
Correct Answer: A
Rationale: An AED analyzes rhythms and delivers shocks for ventricular fibrillation or pulseless ventricular tachycardia. Cardioversion, oxygen monitoring, and compressions are not AED functions.
The ED nurse is caring for the client who has taken an overdose of cocaine. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Evaluate the airway and breathing.
- B. Monitor the rate of intravenous fluids.
- C. Place the cardiac monitor on the client.
- D. Transfer the client to the intensive care unit.
Correct Answer: C
Rationale: Placing a cardiac monitor is a technical task delegable to UAPs. Airway evaluation, IV monitoring, and transfers require nursing judgment.
The male client was found in a parked car with the motor running. The paramedic brought the client to the ED with complaints of a headache, nausea, and dizziness and the client is unable to recall his name or address. On assessment, the nurse notes the buccal mucosa is a cherry-red color. Which intervention should the nurse implement first?
- A. Check the client’s oxygenation level with a pulse oximeter.
- B. Apply oxygen via nasal cannula at 100%.
- C. Obtain a psychiatric consult to determine if this was a suicide attempt.
- D. Prepare the client for transfer to a facility with a hyperbaric chamber.
Correct Answer: B
Rationale: Cherry-red mucosa suggests carbon monoxide (CO) poisoning; 100% oxygen via non-rebreather mask is the first intervention to displace CO. Pulse oximetry is unreliable, psychiatric consults are secondary, and hyperbaric transfer follows initial stabilization.