Nokea
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.
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An 83-year-old patient is brought in by ambulance from a long-term care facility. The patient's symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage. Why would this be true?
- A. Older adults may have an altered response to treatment.
- B. Older adults are often reluctant to adhere to prescribed treatment.
- C. Older adults have difficulty giving a health history.
- D. Older adults often stigmatize their peers who use the ED.
Correct Answer: A
Rationale: Older adults may have atypical presentations or altered treatment responses, complicating emergency management. Nonadherence, history difficulties, or stigmatization are not primary issues.
A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding?
- A. Absence of bruising at contusion sites
- B. Rapid pulse and decreased capillary refill
- C. Increased BP with narrowed pulse pressure
- D. Sudden diaphoresis
Correct Answer: B
Rationale: Rapid pulse and poor capillary refill suggest hypovolemia from internal hemorrhage. Increased BP or diaphoresis alone are less specific, and bruising absence doesn't rule it out.
Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below?
- A. A patient with a blunt chest trauma with some difficulty breathing
- B. A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar
- C. A patient with a possible fractured tibia with adequate pedal pulses
- D. A patient with an acute onset of confusion
Correct Answer: A
Rationale: Blunt chest trauma with breathing difficulty suggests a compromised airway, which is a life-threatening emergency requiring immediate attention. Neck pain, a stable fracture, and confusion are less urgent.
An obtunded patient is admitted to the ED after ingesting bleach. The nurse should prepare to assist with what intervention?
- A. Prompt administration of an antidote
- B. Gastric lavage
- C. Administration of activated charcoal
- D. Helping the patient drink large amounts of water
Correct Answer: D
Rationale: Diluting bleach ingestion with water is appropriate for corrosive substances. There's no antidote, lavage is contraindicated, and charcoal is ineffective for corrosives.
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.