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The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses who provide care in a desert region. The educator should describe what sign or symptom?
- A. Hypertension with a wide pulse pressure
- B. Anhidrosis
- C. Copious diuresis
- D. Cheyne-Stokes respirations
Correct Answer: B
Rationale: Heat stroke is characterized by anhidrosis (lack of sweating), hot dry skin, and hyperthermia. It causes hypotension, not hypertension, and is not linked to diuresis or Cheyne-Stokes breathing.
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You are a floor nurse caring for a patient with alcohol withdrawal syndrome. What would be an appropriate nursing action to minimize the potential for hallucinations?
- A. Engage the patient in a process of health education.
- B. Administer opioid analgesics as ordered.
- C. Place the patient in a private, well-lit room.
- D. Provide television or a radio as therapeutic distraction
Correct Answer: C
Rationale: A quiet, well-lit private room reduces sensory overload, minimizing hallucinations in alcohol withdrawal. Analgesics or media may worsen symptoms, and education is inappropriate during acute withdrawal.
The paramedics bring a patient who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim?
- A. Respect the patient's privacy during assessment.
- B. Shave all pubic hair for laboratory analysis.
- C. Place items for evidence in plastic bags.
- D. Bathe the patient before the examination.
Correct Answer: A
Rationale: Respecting privacy minimizes trauma during a sexual assault assessment. Pubic hair is combed, not shaved; evidence goes in paper bags to avoid moisture; and bathing destroys evidence.
A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patient's peritoneum, the nurse should anticipate what diagnostic test?
- A. Radiograph
- B. Computed tomography (CT) scan
- C. Complete blood count (CBC)
- D. Barium swallow
Correct Answer: B
Rationale: CT scans effectively detect intraperitoneal injuries from blunt trauma. Radiographs are less detailed, CBC indicates blood loss but not location, and barium swallow is irrelevant.
A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what?
- A. Liver
- B. Small bowel
- C. Stomach
- D. Large bowel
Correct Answer: B
Rationale: Penetrating abdominal injuries, like gunshot wounds, frequently damage hollow organs, with the small bowel being most common due to its large surface area. The liver is a solid organ.
A patient has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the patient's bladder is distended. What is the nurse's most appropriate action?
- A. Withhold fluids from the patient.
- B. Perform intermittent urinary insertionization before.
- C. Insert a narrow-gauge indwelling in the urinary catheter.
- D. D) Await orders following the urologist's assessment.
Correct Answer: D
Rationale: Await orders following the urologist's assessment. Urethral injury may contraindicate catheterization, so urologic consultation is needed first. Withholding fluids is secondary.