Chapter 34 Emergency Room and Urgent Care Nursing

Chapter 34 Emergency Room and Urgent Care Nursing

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)An adult male is brought to an urgent care facility by a neighbor. The client states that he wasworking on his car and something flew into his eye. Neither the client nor the neighbor did anyintervention prior to coming to urgent care. The client says that there is definitely something in hiseye. What should be the first action by the nurse?1)A)Assess the eye to determine if there is a foreign object present.B)Obtain admission vital signs, including pain level.C)Flush the eye with sterile water and cover with a sterile eye pad.D)Have the client be seen by a physician immediately.Answer:DExplanation:A)A client with a suspected foreign object in the eye should be immediatelyexamined by a physician. The nurse should not perform any interventions prior tothis, because any physical intervention can increase the risk of eye injury. Thenurse does not need to first confirm the client’s statements that something is still inhis eye. There is no information in the scenario to suggest that obtaining vital signsshould be the priority nursing action for this client.EvaluationPhysiological Integrity-Physiological AdaptationAnalysisB)A client with a suspected foreign object in the eye should be immediatelyexamined by a physician. The nurse should not perform any interventions prior tothis, because any physical intervention can increase the risk of eye injury. Thenurse does not need to first confirm the client’s statements that something is still inhis eye. There is no information in the scenario to suggest that obtaining vital signsshould be the priority nursing action for this client.EvaluationPhysiological Integrity-Physiological AdaptationAnalysisC)A client with a suspected foreign object in the eye should be immediatelyexamined by a physician. The nurse should not perform any interventions prior tothis, because any physical intervention can increase the risk of eye injury. Thenurse does not need to first confirm the client’s statements that something is still inhis eye. There is no information in the scenario to suggest that obtaining vital signsshould be the priority nursing action for this client.EvaluationPhysiological Integrity-Physiological AdaptationAnalysisD)A client with a suspected foreign object in the eye should be immediatelyexamined by a physician. The nurse should not perform any interventions prior tothis, because any physical intervention can increase the risk of eye injury. Thenurse does not need to first confirm the client’s statements that something is still inhis eye. There is no information in the scenario to suggest that obtaining vital signsshould be the priority nursing action for this client.EvaluationPhysiological Integrity-Physiological AdaptationAnalysis1
2)A client is brought into the emergency room by ambulance after the client was found by aroommate lying on the floor next to an empty bottle of acetylsalicylic acid (aspirin). The client canbe aroused and answers questions slowly and sluggishly. It is not known at this time whether theingestion was accidental or intentional. What should be the priority nursing assessment for thisclient?2)A)Frequently ask the client if she is experiencing ringing in her ears or any visual problems.B)Observe respiratory rate and depth every 15 minutes or more often if indicated.C)Verify whether the overdose was accidental or intentional.D)Determine whether the client has any physical signs of Reye’s syndrome.Answer:BExplanation:A)The first manifestations of acute salicylate poisoning include hyperpnea with anincrease in respiration depth. Acidosis and electrolyte imbalance may follow.Reye’s syndrome is associated with a group of symptoms that may appearfollowing a viral infection. The cause is unknown, and aspirin has been associatedwith its onset. Tinnitus is considered a sign of aspirin toxicity, not salicylatepoisoning. Tinnitus is more likely to occur with aspirin usage over time, not as animmediate symptom with acute poisoning. Verifying whether the overdose wasaccidental or intentional addresses safety and psychosocial needs and should nottake priority over physiological needs. The client may or may not haveintentionally taken an overdose of aspirin. Without knowing this information, thenurse should institute suicide precautions with the client.AssessmentPhysiological Integrity-Physiological AdaptationApplicationB)The first manifestations of acute salicylate poisoning include hyperpnea with anincrease in respiration depth. Acidosis and electrolyte imbalance may follow.Reye’s syndrome is associated with a group of symptoms that may appearfollowing a viral infection. The cause is unknown, and aspirin has been associatedwith its onset. Tinnitus is considered a sign of aspirin toxicity, not salicylatepoisoning. Tinnitus is more likely to occur with aspirin usage over time, not as animmediate symptom with acute poisoning. Verifying whether the overdose wasaccidental or intentional addresses safety and psychosocial needs and should nottake priority over physiological needs. The client may or may not haveintentionally taken an overdose of aspirin. Without knowing this information, thenurse should institute suicide precautions with the client.AssessmentPhysiological Integrity-Physiological AdaptationApplicationC)The first manifestations of acute salicylate poisoning include hyperpnea with anincrease in respiration depth. Acidosis and electrolyte imbalance may follow.Reye’s syndrome is associated with a group of symptoms that may appearfollowing a viral infection. The cause is unknown, and aspirin has been associatedwith its onset. Tinnitus is considered a sign of aspirin toxicity, not salicylatepoisoning. Tinnitus is more likely to occur with aspirin usage over time, not as animmediate symptom with acute poisoning. Verifying whether the overdose wasaccidental or intentional addresses safety and psychosocial needs and should nottake priority over physiological needs. The client may or may not haveintentionally taken an overdose of aspirin. Without knowing this information, thenurse should institute suicide precautions with the client.AssessmentPhysiological Integrity-Physiological AdaptationApplication2
D)The first manifestations of acute salicylate poisoning include hyperpnea with anincrease in respiration depth. Acidosis and electrolyte imbalance may follow.Reye’s syndrome is associated with a group of symptoms that may appearfollowing a viral infection. The cause is unknown, and aspirin has been associatedwith its onset. Tinnitus is considered a sign of aspirin toxicity, not salicylatepoisoning. Tinnitus is more likely to occur with aspirin usage over time, not as animmediate symptom with acute poisoning. Verifying whether the overdose wasaccidental or intentional addresses safety and psychosocial needs and should nottake priority over physiological needs. The client may or may not haveintentionally taken an overdose of aspirin. Without knowing this information, thenurse should institute suicide precautions with the client.AssessmentPhysiological Integrity-Physiological AdaptationApplication3)A confused client admitted to an emergency room pulls out his intravenous line. A nurse sustains aneedle stick during this time. What should be the nurse’s initial action?3)A)Go immediately to the facility’s Occupation or Employee Health Department to be seen.B)Call the Needlestick Hotline.C)Promote bleeding in the site of the stick and flush under cold running water.D)Determine if the client is HIV-positive.Answer:CExplanation:A)The concern is transmission of a bloodborne infection, such as HIV or hepatitis B orC. Immediately promoting bleeding may minimize the amount of blood thatreaches the systemic circulation. Cold water does not coagulate protein andclotting at the site is delayed. After doing this, the nurse should notify the facility’sOccupational or Employee Health Department. Calling the Needlestick Hotline isalso appropriate after the initial interventions. Facilities may have individualpolicies regarding needlesticks. The client is confused, so this may limit theamount of reliable information that can be obtained. It is unknown what otherresources about the client’s history are available.ImplementationSafe, Effective Care Environment-Safety and Infection ControlAnalysisB)The concern is transmission of a bloodborne infection, such as HIV or hepatitis B orC. Immediately promoting bleeding may minimize the amount of blood thatreaches the systemic circulation. Cold water does not coagulate protein andclotting at the site is delayed. After doing this, the nurse should notify the facility’sOccupational or Employee Health Department. Calling the Needlestick Hotline isalso appropriate after the initial interventions. Facilities may have individualpolicies regarding needlesticks. The client is confused, so this may limit theamount of reliable information that can be obtained. It is unknown what otherresources about the client’s history are available.ImplementationSafe, Effective Care Environment-Safety and Infection ControlAnalysis3
C)The concern is transmission of a bloodborne infection, such as HIV or hepatitis B orC. Immediately promoting bleeding may minimize the amount of blood thatreaches the systemic circulation. Cold water does not coagulate protein andclotting at the site is delayed. After doing this, the nurse should notify the facility’sOccupational or Employee Health Department. Calling the Needlestick Hotline isalso appropriate after the initial interventions. Facilities may have individualpolicies regarding needlesticks. The client is confused, so this may limit theamount of reliable information that can be obtained. It is unknown what otherresources about the client’s history are available.ImplementationSafe, Effective Care Environment-Safety and Infection ControlAnalysisD)The concern is transmission of a bloodborne infection, such as HIV or hepatitis B orC. Immediately promoting bleeding may minimize the amount of blood thatreaches the systemic circulation. Cold water does not coagulate protein andclotting at the site is delayed. After doing this, the nurse should notify the facility’sOccupational or Employee Health Department. Calling the Needlestick Hotline isalso appropriate after the initial interventions. Facilities may have individualpolicies regarding needlesticks. The client is confused, so this may limit theamount of reliable information that can be obtained. It is unknown what otherresources about the client’s history are available.ImplementationSafe, Effective Care Environment-Safety and Infection ControlAnalysis