Nokea
The nurse is assessing a patient admitted to the emergency department (ED) with a broken arm and facial bruises and notes multiple bruising in various stages of healing. Which of the following responses by the nurse is most appropriate?
- A. Is someone at home hurting you?
- B. You should not return to your home
- C. Would you like to see a social worker?
- D. I have to report this abuse to the police
Correct Answer: A
Rationale: Multiple bruises in various stages of healing suggest possible abuse. The nurse's initial response should be to assess further by asking about potential abuse sensitively, before taking other actions like reporting or involving social services.
You may also like to solve these questions
A patient's family members are in the patient room when the patient has a cardiac arrest and emergency personnel start resuscitation measures. Which of the following actions should the nurse take first?
- A. Have the family wait outside the patient room with a designated staff member to provide emotional support
- B. Keep the family in the room and assign a member of the team to explain the care given and answer questions
- C. Ask the family members about whether they would prefer to remain in the patient room or wait outside the room
- D. Advise the family members that patients are comforted by having family members present during resuscitation efforts
Correct Answer: C
Rationale: Assessing family preferences first respects their emotional needs and informs subsequent actions. Some families benefit from staying, while others prefer to leave, and this decision guides whether to provide support in or out of the room.
The nurse is caring for a patient with hypotension and temperature elevation after doing yard work on a hot day and is being treated in the emergency department. After the nurse has completed discharge teaching, which of the following patient statements indicates that the teaching has been effective?
- A. I will take salt tablets when I work outdoors in the summer
- B. I should take acetaminophen if I start to feel too warm
- C. I should have sports drinks when exercising outside in hot weather
- D. I will get into a cool environment if I notice that I am feeling confused
Correct Answer: C
Rationale: Sports drinks replace fluids and electrolytes lost during heat exposure, preventing heat-related illnesses. Salt tablets risk gastric irritation, antipyretics like acetaminophen are ineffective for heat-induced hyperthermia, and confusion indicates severe heat stroke requiring immediate medical intervention.
The emergency department (ED) nurse is admitting a patient with a left forearm laceration that is bleeding profusely. The health care provider has prescribed that the nurse remove the patient's rings from the left hand. Which of the following actions should the nurse take first?
- A. Apply a clean dressing to the laceration
- B. Elevate the left arm above heart level
- C. Remove the rings from the patient's hand
- D. Insert an 18-gauge IV in the right arm
Correct Answer: C
Rationale: Removing the rings first prevents complications from swelling, which could impair circulation if the rings are left in place. Other actions like dressing the wound or elevating the arm follow to control bleeding.
The nurse is caring for a patient who has experienced blunt abdominal trauma during a car accident and has increasing abdominal pain. Which of the following diagnostic tests should the nurse prepare the patient for?
- A. Ultrasonography
- B. Peritoneal lavage
- C. X-ray
- D. Magnetic resonance imaging (MRI)
Correct Answer: A
Rationale: Focused abdominal ultrasonography (FAST) is the preferred, non-invasive method to detect intraperitoneal bleeding in trauma patients. Peritoneal lavage is more invasive, and X-ray or MRI are less effective for this purpose.
A patient who is unconscious after a fall from a ladder is transported to the emergency department by family members. During the primary survey of the patient, which of the following actions should the nurse implement?
- A. Assess the patient's vital signs
- B. Attach a cardiac electrocardiogram (ECG) monitor
- C. Obtain a Glasgow Coma Scale score
- D. Ask about chronic medical conditions
Correct Answer: C
Rationale: The Glasgow Coma Scale score assesses neurological disability during the primary survey, prioritizing evaluation of consciousness in an unconscious trauma patient. Vital signs and medical history are part of the secondary survey.