The nurse is caring for a patient in the emergency department with a gunshot wound to the chest. The nurse observes carefully for signs and symptoms of tension pneumothorax. Which of the following will be seen FIRST:
B. Crackles sound audible on inspection
C. Restlessness, sudden onset of persistent chest pain and
A client diagnosed with Bipolar disorder exhibits square dancing, unkempt appearance and have not slept for 36 hours. The MOST IMPORTANT nursing care appropriate for this client during manic episodes will be:
A. Confront the client’s inappropriate dancing and bad body odor
B. Send client to chestboard game to divert client’s energy
A client with a spinal cord injury at the level of C4 has a weakened respiratory effort, ineffective cough, and is using accessory muscles in breathing. The nurse carefully monitors of the following nursing diagnoses?
A client for whom NARDIL was prescribed for depression is brought to the ER with severe occipital headaches for eating pepperoni pizza for lunch. Which of the following interpretation is it important for the nurse to make regarding these findings?
A. Allergic reaction related to ingestion of processed food
B. Hypertensive crisis related to drug and food reaction
C. Panic anxiety related to unresolved issues, uncontrolled anxiety
D. Ineffective individual coping related to MAOI treatment
2. Use the Nursing Process (APIE) to establish priorities. You must first assess, then plan, then implement, and finally evaluate. Select responses in which you assess the client before you implement the care.
3 . Use ABC’s . When you encounter a question that requires you to establish priorities, think airway, breathing, and then circulation. Your first priority in an emergency situation would be to establish a patient airway.
4. Use RACE . When you see priority questions that deal with fires, think: remove the clients, the sound the alarm, call the fire department, and finally extinguish the fire. The safety of the clients is the first priority.