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The nurse writes a nursing diagnosis of 'risk for injury as a result of physical abuse by spouse' for a client. Which is an appropriate goal for this client?
- A. The client will learn not to trust anyone.
- B. The client will admit the abuse is happening and get help.
- C. The client will discuss the nurse’s suspicions with the spouse.
- D. The client will choose to stay with the spouse.
Correct Answer: B
Rationale: Admitting abuse and seeking help is a realistic goal to reduce injury risk. Distrust, confronting the spouse, or staying are unsafe or neutral.
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The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client?
- A. Cool, moist skin.
- B. Bradycardia.
- C. Wheezing.
- D. Decreased bowel sounds.
Correct Answer: B
Rationale: Neurogenic shock causes bradycardia due to loss of sympathetic tone. Cool, moist skin is typical of hypovolemic shock, wheezing suggests anaphylaxis, and decreased bowel sounds are non-specific.
The nurse is providing first aid to a victim of a poisonous snake bite. Which intervention should be the nurse’s first action?
- A. Apply a tourniquet to the affected limb.
- B. Cut an 'X' across the bite and suck out the venom.
- C. Administer a corticosteroid medication.
- D. Have the client lie still and remove constrictive items.
Correct Answer: D
Rationale: Immobilizing the limb and removing constrictive items (e.g., jewelry) prevents venom spread and swelling, the first action. Tourniquets, cutting, and steroids are outdated or secondary.
During a disaster, a local news reporter comes to the emergency department requesting information about the victims. Which action is most appropriate for the nurse to implement?
- A. Have security escort the reporter off the premises.
- B. Direct the reporter to the disaster command post.
- C. Tell the reporter this is a violation of HIPAA.
- D. Request the reporter to stay out of the way.
Correct Answer: B
Rationale: Directing the reporter to the command post ensures controlled information release, adhering to HIPAA. Escorting off, citing HIPAA, or requesting to stay out are less collaborative.
The occupational health nurse is called to the scene of a traumatic amputation of a finger. Which intervention should the nurse implement prior to sending the client to the ED? Select all that apply.
- A. Rinse the amputated finger with sterile normal saline.
- B. Place the amputated finger in a sealed and watertight plastic bag.
- C. Place the amputated finger into iced saline solution.
- D. Wrap the amputated finger in saline-moistened gauze dressings.
- E. Replace the amputated finger on the hand and wrap with gauze.
Correct Answer: A,B,D
Rationale: Rinsing with saline, wrapping in moist gauze, and sealing in a plastic bag preserve the amputated finger for reimplantation. Iced saline damages tissue, and replacing on the hand is incorrect.
The ED nurse is completing the initial assessment on a client who becomes unresponsive. Which intervention should the nurse implement first?
- A. Assess the rate and site of the intravenous fluid.
- B. Administer an ampule of sodium bicarbonate.
- C. Assess the cardiac rhythm shown on the monitor.
- D. Prepare to cardiovert the client into sinus rhythm.
Correct Answer: C
Rationale: Assessing the cardiac rhythm determines the cause of unresponsiveness (e.g., arrhythmia), guiding ACLS interventions. IV checks, bicarbonate, and cardioversion follow.