Med Surg II ch.63In the event of poisoning, what is the priority intervention? Show
Most cases of food poisoning can be attributed to which factor? Which symptoms of severe airway obstruction would prompt a nurse to intervene and activate anemergency response? Select all that apply. The nurse is assessing a victim of a motor vehicle accident in the emergency department. Whichsymptom would alert the nurse that the patient may be going into hemorrhagic shock? In disaster situations, which is a correct statement regarding the purpose of Health Insurance Portabilityand Accountability Act (HIPAA) Privacy Rules? The student nurse is caring for a patient who develops epistaxis. Which initial intervention demonstratesa knowledge of the patient care given for epistaxis? Death of a victim of carbon monoxide poisoning usually occurs when the carbon monoxide bound withhemoglobin exceeds which value? A patient is recovering from abdominal surgery. While assisting the patient to a chair, a ripping sound isheard and the nurse can see loops of bowel through the incision when the bandage is pulled back. Thenurse helps the patient back to bed and covers the wound with a sterile saline dressing. The nurse callsthe health care provider to report which event?A 5-year-old patient is admitted to the emergency department with a compound fracture of the left arm after falling out of a tree. Which signs of injury would the nurse expect? A pregnant woman is choking. She is responsive but clutching her neck, is unable to speak or cough, andhas no air exchange. Firm thrusts need to be delivered by standing behind the woman and positioningthe hands in which manner? What is the immediate treatment for external bleeding? The nurse is teaching a community class at a junior high school on first aid care of a fracture. Whichstatement by a student demonstrates understanding of the material presented? The licensed practical nurse (LPN) arrives at an accident scene. The victim is screaming loudly, and hisclothes are on fire. What would be the first nursing intervention for this patient? The nurse is a first responder to the scene of a motor vehicle accident. Which symptom would alert thenurse to a possible basilar skull fracture? Chapter 11: Concepts of Care for Patients With Common Environmental EmergenciesMULTIPLE CHOICE
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Environmental emergencies, Heat-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Environmental emergencies, Bee and insect stings MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Environmental emergencies, Cold-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
ANS: A The client is exhibiting signs of mountain sickness and high-altitude cerebral edema (HACE). Dexamethasone reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not specifically treat HACE, although a thorough mental status exam would be performed. DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Environmental emergencies, Altitude-related illness MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
ANS: A Clients who survive a lightning strike can have serious myocardial injury, which can be manifested by ECG and myocardial perfusion abnormalities. The nurse would prioritize the ECG over the other assessments which would be completed later. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Environmental emergencies, Lightning injury MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
ANS: A People would never swim alone, regardless of lifeguard status. The other statements indicate good understanding of the teaching. DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Environmental emergencies, Drowning, Health teaching MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Environmental emergencies, Cold-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Environmental emergencies, Snakebites MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
ANS: B For the client with a snakebite, the nurse would contact the regional poison control center immediately for specific advice on antivenom administration and client management. DIF: Remembering TOP: Integrated Process: Nursing Process: Planning KEY: Environmental emergencies, Snakebites MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
ANS: B The client is exhibiting signs of AMS with high-altitude pulmonary edema (HAPE). Cyanosis indicates hypoxia and must be treated immediately. A complete pulmonary assessment and ABG analysis are indicated but the priority is oxygen administration. Acetazolamide is used to prevent AMS. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Environmental emergencies, Altitude-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE
DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Environmental emergencies, Cold-related illness, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
ANS: A, B, E, F To prevent arthropod bites and stings, patients should wear protective clothing, cover garbage cans, use screens in wind ows and doors, inspect clothing and shoes before putting them on, consult an exterminator, remove nests, avoid swatting at insects, and carry a prescription epinephrine autoinjector at all times if they are known to be allergic to bee or wasp stings. Shoes are needed when working in areas known or suspected to harbor arthropods, but sandals will not protect the feet. Removing nesting sites may help eliminate the population. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Environmental emergencies, Bee and insect sting, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance
DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Environmental emergencies, Lightning injuries MSC: Client Needs Category: Health Promotion and Maintenance
ANS: A, B, E, F Some of the most vulnerable, at-risk populations for heat-related illness include older adults; people who work outside, such as construction and agricultural workers; homeless people; people who abuse substances; outdoor athletes (recreational and professional); and members of the military who are stationed in countries with hot climates (e., Iraq, Afghanistan). Hockey is generally a cold-air game whether played indoors or outdoors and wouldn’t have as much risk for heat-related illness as other sports. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Environmental emergencies, Heat-related illness MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
DIF: Understanding TOP: Integrated Process: Nursing Process: Planning KEY: Environmental emergencies, Heat-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Environmental emergencies, Heat-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
ANS: A, C, E, F Signs and symptoms of heat stroke include as elevated body temperature (above 104° F [40° C]), mental status changes such as confusion and decreasing level of consciousness, hypotension, tachycardia, and tachypnea. Perspiration is an inconsisten t finding. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Environmental emergencies, Heat-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation Which intervention would the nurse perform when caring for a patient with frostbite?Treatment of frostbite requires rewarming of the affected part using warm water that ranges from 98.6 to 102.2 degrees F, or 37 to 39 degrees C. Additionally, clients should take nonsteroidal anti-inflammatory drugs to relieve pain; and thrombolytics to reduce the risk of thrombosis and reperfusion injury.
Which intervention would the nurse perform for a patient who presents with frostbite on the right toe?Soak frostbitten fingers, toes or other extremities in warm water — 105 to 110 F (about 40 to 43 C). If a thermometer isn't available, test the water by placing an uninjured hand or elbow in it — it should feel very warm, not hot.
What rewarming technique does the nurse use for partial thickness to full thickness frostbite injury?Rewarming can be accomplished by soaking the affected area in warm (not hot) water for 15 to 30 minutes. Rewarming using heat sources such as stoves or heating pads should be avoided, as these can lead to burns.
Which part of the body is most vulnerable to frostbite in a superficial injury?Superficial frostbite, as seen here on the tip of a finger, is most common on the fingers, toes, nose, ears, cheeks and chin. Frostbite is an injury caused by freezing of the skin and underlying tissues.
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