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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.
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A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions?
- A. Insert an oropharyngeal airway.
- B. Perform the jaw thrust maneuver.
- C. Perform endotracheal intubation.
- D. Perform a cricothyroidotomy.
Correct Answer: C
Rationale: Endotracheal intubation ensures airway patency in respiratory insufficiency. Oropharyngeal airways are for spontaneous breathing, jaw thrust doesn't secure an airway, and cricothyroidotomy is a last resort.
A patient with a history of major depression is brought to the ED by her parents. Which of the following nursing actions is most appropriate?
- A. Noting that symptoms of physical illness are not relevant to the current diagnosis
- B. Asking the patient if she has ever thought about taking her own life
- C. Conducting interviews in a brief and direct manner
- D. Arranging for the patient to spend time alone to consider her feelings
Correct Answer: B
Rationale: Screening for suicidal ideation is critical in depression to assess risk. Physical symptoms are relevant, interviews should be empathetic, and leaving the patient alone risks suicide.
A patient with multiple trauma is brought to the ED by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this patient's care?
- A. Intubating the patient
- B. Notifying family members
- C. Ensuring IV access
- D. Delivering specimens to the laboratory
Correct Answer: C
Rationale: Ensuring IV access is a key ED nursing role for administering fluids or medications. Intubation is for specialized providers, family notification is not a nurse's role, and specimen delivery is handled by others.
A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the patient's frostbite?
- A. Immerse affected extremities in water slightly above normal body temperature.
- B. Immerse the patient's frostbitten extremities in the warmest water the patient can tolerate.
- C. Gently massage the patient's frozen extremities in between water baths.
- D. Perform passive range-of-motion exercises of the affected extremities to promote circulation.
Correct Answer: A
Rationale: Immersion in 37-40°C water safely rewarms frostbitten extremities. Hotter water risks burns, and massage or exercises cause further tissue damage.
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.