A patient is admitted to the emergency department after being involved in a motor vehicle accident
The patient has multiple injuries. The first priority for this patient is to establish airway and ventilation. What would be the next priority in this patient's care?
A) Control hemorrhage
B) Assess for head and neck injuries
C) Splint fractures
D) Prevent and treat hypovolemic shock
Ans: A
Feedback: (1) Establish airway and ventilation, (2) control hemorrhage, (3) prevent and treat hypovolemic shock, (4) assess for head and neck injuries, (5) evaluate for other injuries— reassess head and neck, chest; assess abdomen, back, and extremities, (6) splint fractures, and (7) perform a more thorough and ongoing examination and assessment.
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When the nurse performs the Nitrazine test on vaginal secretions of a patient who thinks her membranes have ruptured, the paper turns yellow. What does this finding indicate?
a. Acidic discharge, membranes intact b. Acidic discharge, membranes have ruptured c. Neutral, not enough discharge to measure d. Alkaline, membranes have ruptured
A patient is admitted to the Neuro ICU with a C4 spinal cord injury. When writing the plan of care for this patient, what nursing diagnoses would the nurse document as a priority for this patient?
A) Risk for impaired skin integrity related to immobility and sensory loss B) Impaired physical mobility related to loss of motor function C) Ineffective breathing patterns related to weakness of the intercostal muscles D) Urinary retention related to inability to void spontaneously
The nursing student is discussing an assigned client's pain responses with the nursing instructor. The student reports feeling amazed about how the client has continued to avoid taking any analgesics only hours after surgery
What response by the nursing instructor is indicated? 1. "Sometimes clients just don't need any analgesics." 2. "Have you seen any nonverbal cues that might indicate the client is experiencing pain?" 3. "We will need to contact the healthcare provider to report the client's continued refusal of analgesics." 4. "Do the client's vital signs indicate the client is experiencing pain?"
The student learning about chronic disease and illness in the older population learns which facts about this situation? (Select all that apply.)
a. One in two adults, or more than 133,000 Americans, has a chronic condition. b. Chronic disease is the leading cause of death in those over 65. c. About 75% of medical costs each year are spent on managing chronic disease. d. Formerly acute conditions are now mana-geable chronic diseases.. e. The focus of America's health care ser-vices is now on chronic illness