Nokea
The nurse stops at the scene of a motor-vehicle accident and provides emergency first aid at the scene. Which law protects the nurse as a first responder?
- A. The First Aid Law.
- B. Ombudsman Act.
- C. Good Samaritan Act.
- D. First Responder Law.
Correct Answer: C
Rationale: The Good Samaritan Act (C) protects nurses providing emergency care from liability. First Aid Law (A) and First Responder Law (D) are not standard, and Ombudsman Act (B) is unrelated.
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The nurse is preparing the male client for an electroencephalogram (EEG). Which intervention should the nurse implement?
- A. Explain that this procedure is not painful.
- B. Premedicate the client with a benzodiazepine drug.
- C. Instruct the client to shave all facial hair.
- D. Tell the client it will cause him to see 'floaters.'
Correct Answer: A
Rationale: Explaining that the EEG is painless (A) reduces anxiety. Benzodiazepines (B) are not routine, shaving (C) is unnecessary, and floaters (D) are not associated.
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 just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement?
- A. Perform a complete neurological assessment.
- B. Awaken the client every 30 minutes.
- C. Turn the client to the side and allow the client to sleep.
- D. Interview the client to find out what caused the seizure.
Correct Answer: C
Rationale: Post-seizure, the client is in a postictal phase with lethargy. Turning to the side (C) prevents aspiration and allows safe rest. Neurological assessment (A) can wait until the client is less lethargic, frequent awakening (B) is unnecessary if oriented, and interviewing (D) is not urgent.
Which finding in a brain-dead client confirms the diagnosis?
- A. Presence of gag reflex
- B. Apnea during an apnea test
- C. Reactive pupils
- D. Spontaneous limb movement
Correct Answer: B
Rationale: Apnea during an apnea test (no spontaneous breathing) is a key criterion for confirming brain death.
Which nursing actions are essential when finding a client experiencing a tonic-clonic seizure? Select all that apply.
- A. Calling out the client's name
- B. Padding the client's body during the seizure activity
- C. Placing an emesis basin close to the client's mouth
- D. Rolling the client's body to the side
- E. Removing environmental hazards to protect the client
- F. Calling the respiratory therapy department
Correct Answer: D,E
Rationale: Rolling the client to the side prevents aspiration, and removing environmental hazards minimizes injury risk during a tonic-clonic seizure.