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A&C Med Surg Iggy Ch 10

Terms in this set (20)

1. An emergency department nurse assesses a client who has been raped. With which health care team member would the nurse collaborate when planning this client's care?
a. Primary health care provider
b. Case manager
c. Forensic nurse examiner
d. Psychiatric crisis nurse
ANS: C
All other members of the health care team listed may be used in the management of this client's care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.
2. The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives. Which action would the nurse take first?
a. Request that the client's spouse sit in the waiting room.
b. Ask the spouse if he or she wishes to be present during the resuscitation.
c. Suggest that the spouse begin to pray for the patient.
d. Refer the client's spouse to the hospital's crisis team.
ANS: B
If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.
3. An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first?
a. A 30-year-old distraught mother holding her crying child
b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48 year old with a simple fracture of the lower leg
ANS: C
The client with pale, cool, clammy skin may be in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.
4. While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action would the nurse take first?
a. Apply oxygen via nasal cannula.
b. Administer intravenous 0.9% saline solution.
c. Transfer the client to a negative-pressure room.
d. Obtain a sputum culture and sensitivity.
ANS: C
A client with signs and symptoms of tuberculosis or other airborne pathogens would be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department. The client may or may not need oxygen or an IV. A sputum culture would be obtained but is not the priority.
5. A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first?
a. A 22 year old with a painful and swollen right wrist
b. A 45 year old reporting chest pain and diaphoresis
c. A 60 year old reporting difficulty swallowing and nausea
d. An 81 year old, respiratory rate 28 breaths/min and temperature of 101° F (38.8°C)
ANS: B
A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.
6. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?
a. Level I—located within remote areas and provides advanced life support within resource capabilities
b. Level II—located within community hospitals and provides care to most injured clients
c. Level III—located in rural communities and provides only basic care to clients
d. Level IV—located in large teaching hospitals and provides a full continuum of trauma care for all clients
ANS: B
Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher level trauma centers are made.
7. Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action would the nurse take first?
a. Assess that the client is breathing adequately.
b. Insert a large-bore intravenous line.
c. Place the client on a cardiac monitor.
d. Assess for the best neurologic response.
ANS: A
After establishing an airway, the highest priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place. Inserting an IV line and placing the client on a monitor would come after ensuring a patent airway and effective breathing.
8. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action would the nurse take prior to providing advanced cardiac life support?
a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic.
ANS: B
Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions would be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers. It is not known if this client has orthopedic injuries. The Rapid Response Team is not needed in the ED. A complete history is needed but the staff's protection comes first.
9. A nurse is triaging clients in the emergency department. Which client would be considered "urgent"?
a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
c. A 75-year-old female with a cough and a temperature of 102° F (38.9° C)
d. A 50-year-old male with new-onset confusion and slurred speech
ANS: C
A client with a cough and a temperature of 102° F (38.9° C) is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech would be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.
10. An emergency department nurse is caring for a client who has died from a suspected homicide. Which action does the nurse take?
a. Remove all tubes and wires in preparation for the medical examiner.
b. Limit the number of visitors to minimize the family's trauma.
c. Consult the bereavement committee to follow up with the grieving family.
d. Communicate the client's death to the family in a simple and concrete manner.
ANS: D
When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family would be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee would be consulted, but this is not the priority at this time.
11. An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention would the case manager provide?
a. Communicate client needs and restrictions to support staff.
b. Prescribe low-cost antibiotics to treat community-acquired infection.
c. Provide referrals to subsidized community-based health clinics.
d. Offer counseling for substance abuse and mental health disorders.
ANS: C
Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, Isolation Precautions) to ensure that ongoing client and staff safety issues are addressed. The ED provider prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.
12. An emergency department nurse is caring for a client who is homeless. Which action would the nurse take to gain the client's trust?
a. Speak in a quiet and monotone voice.
b. Avoid eye contact with the patient.
c. Listen to the client's concerns and needs.
d. Ask security to store the client's belongings.
ANS: C
To demonstrate behaviors that promote trust with homeless clients, the emergency department nurse makes eye contact (if culturally appropriate), speaks calmly, avoids any prejudicial or stereotypical remarks, shows genuine care and concern by listening, and follows through on promises. The nurse would also respect the client's belongings and personal space.
13. A nurse is triaging clients in the emergency department. Which client would the nurse classify as "nonurgent?"
a. A 44 year old with chest pain and diaphoresis
b. A 50 year old with chest trauma and absent breath sounds
c. A 62 year old with a simple fracture of the left arm
d. A 79 year old with a temperature of 104°F.(40.0° C)
ANS: C
A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.
14. What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department?
a. Determine the acuity of the client's condition to determine priority of care.
b. Assess the status of the airway, breathing, circulation, or presence of deficits.
c. Determine whether the client is responsive enough to provide needed information.
d. Evaluate the emergency department's resources to adequately treat the patient.
ANS: A
ED triage is an organized system for sorting and classifying clients into priority levels depending on illness or injury severity. The primary goal of the triage system is to facilitate the ED nurse's ability to prioritize care according to the acuity of the patient, having the clients with the more severe illness or injury seen first. Airway, breathing, and circulation are part of the primary survey. Determining responsiveness is done during the disability phase of the primary survey and is not the primary goal. Evaluating the ED's resources is also not a goal of triage.
15. An elderly client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient?
a. A full set of vital signs
b. Cardiac rhythm
c. Neurologic status
d. Client history
ANS: C
The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. Injuries from this type of fall have a high risk for cervical spine injuries. In addition, with the loss of consciousness at the scene the client would be at risk for head trauma. A full set of vital signs is obtained as part of the
secondary survey. The cardiac rhythm is important but not specifically related to this client's presentation. Client history would be obtained as able.
1. A nurse is caring for clients in a busy emergency department. What actions would the nurse take to ensure client and staff safety? (Select all that apply.)
a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom.
b. Use two identifiers before each intervention and before mediation administration.
c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.
d. Search the belongings of clients with altered mental status to gain essential medical information.
e. Use facility policy identification procedures for "Jane/John Doe" clients.
f. Check clients for a medical alert bracelets or necklaces.
g. Avoid using Security personnel to prevent escalation of client behaviors.
ANS: B,C,D,E,F
Best practices for client and staff safety in the emergency department include leaving beds in the lowest position with side rails up, using two unique identifiers for medications and procedures, using de-escalation strategies for clients or visitors showing hostile or aggressive behaviors, searching the belongings of confused clients for medical information, using facility identification systems for Jane/John Doe clients, observing for medical alert jewelry, and using security staff as needed.
2. An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information would the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.)
a. Mechanism of injury
b. Diagnostic test results
c. Immunizations
d. List of home medications
e. Isolation Precautions
f. Safety concerns
ANS: A,B,E,F
Hand-off communication would be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication would be concise and would include only the most essential information for a safe transition in care. Hand-off communication would include the client's situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, safety concerns interventions provided, and response to those interventions. Immunization history is not usually considered critical unless it relates to the reason for admission. Medication reconciliation will occur when the client reaches the inpatient unit.
3. An emergency department nurse is caring for a trauma patient. Which interventions does the nurse perform during the primary survey? (Select all that apply.)
a. Foley catheterization
b. Needle decompression
c. Initiating IV fluids
d. Splinting open fractures
e. Endotracheal intubation
f. Removing wet clothing
g. Laceration repair
ANS: B,C,E,F
The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spinal motion restriction; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.
4. The complex care provided during an emergency requires interprofessional collaboration. Which team members are paired with the correct responsibilities? (Select all that apply.)
a. Psychiatric crisis nurse—interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis
b. Forensic nurse examiner—performs rapid assessments to ensure that clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources
c. Triage nurse—provides basic life support interventions such as oxygen, basic wound care, splinting, spinal motion restriction, and monitoring of vital signs
d. Emergency medical technician—obtains client histories, collects evidence, and offers counseling and follow up care for victims of rape, child abuse, and domestic violence
e. Paramedic—provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration
ANS: A,E
The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client's behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure that clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.
5. A nurse prepares to discharge an older adult client home from the emergency department (ED). What actions does the nurse take to prevent future ED visits? (Select all that apply.)
a. Provide medical supplies to the family.
b. Consult a home health agency.
c. Encourage participation in community activities.
d. Screen for depression and suicide.
e. Complete a functional assessment.
ANS: D,E
Due to the high rate of suicide among older adults, a nurse would assess all older adults for depression and suicide. The nurse would also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits.
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