Question 1

The nurse is evaluating care provided to a patient recovering from a psychotic episode.Which patient statement should the nurse recognize as an indication of reduced anxiety?

Accepted Answer

Interventions are successful if the patient reports reduced anxiety.B.Stating an opinion about the nurses does not indicate that interventions have been success for the patient.C.D.Stating that the restraints can be removed and refusing tranquilizers indicate that treatment has not yet been successful for the patient recovering from a psychotic episode.

Question 2

The nurse in the emergency department is caring for a patient with a partial-thickness thermal burn.Which treatment should the nurse expect to be prescribed for this patient?

Accepted Answer

Partial-thickness burns that involve a small area are cleaned with sterile saline solution,covered with a 1/8-inch layer of an anti-infective cream such as silver sulfadiazine (Silvadene,Flamazine),and covered with dry bulky,fluffed dressings.A.Because the skin can no longer protect the patient,wet dressings provide a medium for bacterial invasion.Wet dressings can also cause a decrease in body temperature because the skin can no longer maintain thermoregulation.B.Deep partial-thickness burns should be covered with dry dressings.C.Over-the-counter lotions are never used on a major burn because they can promote infection,retain heat,and cause more pain.

Question 3

The nurse in the emergency department is triaging victims of a building collapse.Which victim should the nurse determine is a priority for care?

Accepted Answer

Patients who are seriously injured and have the greatest chance of full recovery are treated first.C.A severely injured patient with moderate potential for survival would be the second patient treated.B.D.Patients with slight potential for survival or less than 1% chance of survival would not be priorities for care.

Question 4

The nurse is planning care for a patient who experienced a near-drowning.What should the nurse identify as the goal of care for this patient?

Accepted Answer

If a person survives submersion,acute respiratory failure may follow.The incidence of serious pulmonary complications is high in this group,so ensuring the patient's respiratory status is the priority.B.C.D.The goals of care for this patient may or may not include stomach decompression,removing fluid from the lungs,or draining fluid from the stomach.

Question 5

The nurse is preparing teaching for the home treatment of ingested poisons.Which medication is no longer recommended for use at home to induce vomiting for certain ingested poisons?

Accepted Answer

Syrup of ipecac is no longer recommended for at-home treatment of accidental overdose,and evidence shows use of ipecac does not improve patient outcomes.B.Cimetidine (Tagamet)is a medication used for gastric irritation.C.Thiethylperazine (Torecan)is a phenothiazine with antiemetic properties.Prochlorperazine (Compazine)is a medication used for nausea and vomiting.

Question 6

The nurse assists with the provision of an educational program on the symptoms of smallpox.Which response indicates that the participants understand the location that the rash first appears?

Accepted Answer

The characteristic rash of smallpox first appears as small red spots on the tongue and in the mouth.A.B.D.The rash will then appear on the face and extremities and spread to all parts of the body within 24 hours.

Question 7

A patient who has fallen has superficial abrasions and an abdomen that is distended,firm,and tender when touched.Which complication should the nurse consider that this patient is experiencing?

Accepted Answer

The shape of the abdomen is observed to detect distention from intra-abdominal hemorrhage.A.Anaphylaxis is associated with an allergic response.B.Emotional stress would not cause the patient's severe abdominal symptoms.C.A cardiac arrhythmia would not cause the patient's abdominal symptoms.

Question 8

A patient who sustained multiple injuries in a motor vehicle crash is brought to the emergency department.After the primary survey,what should be the nurse's next action?

Accepted Answer

The primary survey of the patient's airway,breathing,circulation,and disability allows recognition,prioritization,and treatment of life-threatening situations.The secondary survey,a rapid head-to-toe assessment,identifies additional serious injuries throughout the body.A.The nurse can explain to the patient what has occurred while conducting the primary or secondary survey.B.The secondary survey will reveal if surgery is indicated for this patient.D.The patient's medical history can be obtained after the secondary survey is completed.

Question 9

The results of a primary survey reveal that a victim of a motor vehicle crash has an open airway,is breathing,and is conscious but bleeding heavily from severe leg injuries.For which complication should the nurse plan care for this client?

Accepted Answer

Hypovolemic shock may occur from a decrease in the circulating blood volume from the bleeding.A.Anaphylaxis is associated with an allergic response.B.Hemothorax is associated with chest injuries.C.Cardiogenic shock is associated with myocardial tissue damage.

Question 10

The physician orders haloperidol (Haldol)2 mg intramuscularly (IM)for a patient who is experiencing a psychiatric crisis.Haldol 5 mg/mL is available.How many milliliters should the nurse give?

Accepted Answer

Using the equation Dosage Required/Dosage Available x mL,the nurse should calculate 2 mg/5 mg ´ 1 mL = 2/5 ´ 1 = 0.4 mL.

Question 11

When using the Glasgow Coma Scale for a patient involved in a motor vehicle crash,the patient opens the eyes when spoken to and points to the location of pain but is confused in conversation.What score should the nurse assign to this patient?

Accepted Answer

Eye opening is scored as a 3.Best verbal response is scored as a 5,and best motor response is scored as a 4.This patient's score would be 12.

Question 12

A patient with a head injury is diagnosed with increased intracranial pressure.In which position should the nurse maintain the patient's head to assist in reducing intracranial pressure?

Accepted Answer

Maintaining the patient's head position at midline ensures unobstructed venous drainage to help reduce ICP.A.C.D.These positions could obstruct venous drainage and increase ICP.

Question 13

The nurse is preparing to care for a client with a poisonous snake wound.Which method should the nurse use to cleanse the site?

Accepted Answer

The site of the bite is cleaned with soap and water.B.C.D.Cytotoxic agents such as hydrogen peroxide and Betadine are not used to clean the wound of a snake bite.

Question 14

The nurse is caring for a patient who was bitten by a snake.Which action should the nurse take to decrease the effects of the venom?

Accepted Answer

Interventions are focused on decreasing the circulation of venom throughout the patient's system by keeping the patient calm and immobilizing the affected part.B.C.D.Elevating the limb,ambulation,and range of motion will encourage the venom to circulate through the patient's system.

Question 15

A patient who has ingested a corrosive product is vomiting.For which potential complication should the nurse prepare to provide care to this client?

Accepted Answer

An ingested substance that is corrosive can cause esophageal burns if vomiting occurs as it travels back up the esophagus.A.Corrosive substances are not directly linked to the development of coma.C.Chemical pneumonia is more likely to develop after an inhalation of a poisonous substance.D.Aspiration pneumonia is more likely to occur if the patient is unable to control or maintain the airway.

Question 16

The nurse ensures that a trauma patient has an effective airway.On what should the nurse focus after the airway has been established for this patient?

Accepted Answer

After the patency of the airway is ensured,the patient is assessed for spontaneous breathing and respiratory rate and depth.D.Circulation is addressed after airway and breathing are established.B.A.Disability and exposure are the focus after the patient has an airway,is breathing,and has an effective heart beat or circulation.

Question 17

A patient is brought to the emergency department after a motor vehicle crash.Which symptom assessed during data collection should the nurse report promptly?

Accepted Answer

Airway and breathing are always the first priority,and wheezing indicates a respiratory issue,so it should be reported.A.Oliguria would be determined during the secondary survey.C.Ecchymosis would indicate injuries which might affect circulation.D.Tachycardia could be an effect of the trauma or from a loss in circulating blood volume.However,the priority is airway and breathing.

Question 18

A patient seeking treatment after being in a house fire has thermal burns to the neck and shoulders and singed nasal hairs.Which action should the nurse take first?

Accepted Answer

Continuous assessment of respiratory status is essential for burns or soot on the face,singed nasal hairs,a hoarse voice,coughing,or restlessness.B.Urine output can be determined at a later time.C.Blood pressure would be determined after the patient's airway and breathing are established.D.There is no reason to place the patient in a private room.

Question 19

The nurse is caring for a patient experiencing acute psychosis.What should the nurse realize as being the purpose of medication for this patient?

Accepted Answer

During a psychotic episode,medications are used to reduce psychosis.A.C.D.Antipsychotic medication is not used to encourage sleep,improve cognition,or enhance oxygenation.

Question 20

The nurse is planning care for a patient with a mental health disorder.Which nursing diagnosis should the nurse select if the patient is demonstrating manic behavior?

Accepted Answer

The patient with manic behavior is at risk for injury because of impaired judgment.A.The person demonstrating manic behavior has not necessarily experienced a loss.B.The person who is demonstrating manic behavior is not confused but rather acting impulsively.D.The person who is demonstrating manic behavior is not experiencing a situation in which defensive coping is necessary.

Quiz 13: Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response