a. Emergency medicine physician
b. Case manager
c. Forensic nurse examiner
d. Psychiatric crisis nurse
All other members of the health care team listed may be used in the management of this client’s care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.
a. Request that the client’s spouse sit in the waiting room.
b. Ask the spouse if he wishes to be present during the resuscitation.
c. Suggest that the spouse begin to pray for the client.
d. Refer the client’s spouse to the hospital’s crisis team.
If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.
a. A 30-year-old distraught mother holding her crying child
b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48-year-old with a simple fracture of the lower leg
The client with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.
a. Apply oxygen via nasal cannula.
b. Administer intravenous 0.9% saline solution.
c. Transfer the client to a negative-pressure room.
d. Obtain a sputum culture and sensitivity.
A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department.
a. A 22-year-old with a painful and swollen right wrist
b. A 45-year-old reporting chest pain and diaphoresis
c. A 60-year-old reporting difficulty swallowing and nausea
d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F
A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.
a. Level I – Located within remote areas and provides advanced life support within resource capabilities
b. Level II – Located within community hospitals and provides care to most injured clients
c. Level III – Located in rural communities and provides only basic care to clients
d. Level IV – Located in large teaching hospitals and provides a full continuum of trauma care for all clients
Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher-level trauma centers are made.
a. Assess that the client is breathing adequately.
b. Insert a large-bore intravenous line.
c. Place the client on a cardiac monitor.
d. Assess for the best neurologic response.
The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place.
a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic.
Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.
a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
c. A 75-year-old female with a cough and a temperature of 102° F
d. A 50-year-old male with new-onset confusion and slurred speech
A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.
a. Remove all tubes and wires in preparation for the medical examiner.
b. Limit the number of visitors to minimize the family’s trauma.
c. Consult the bereavement committee to follow up with the grieving family.
d. Communicate the client’s death to the family in a simple and concrete manner.
When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.
a. Communicate client needs and restrictions to support staff.
b. Prescribe low-cost antibiotics to treat community-acquired infection.
c. Provide referrals to subsidized community-based health clinics.
d. Offer counseling for substance abuse and mental health disorders.
Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.
a. Speak in a quiet and monotone voice.
b. Avoid eye contact with the client.
c. Listen to the client’s concerns and needs.
d. Ask security to store the client’s belongings.
To demonstrate behaviors that promote trust with homeless clients, the emergency room nurse should make eye contact (if culturally appropriate), speak calmly, avoid any prejudicial or stereotypical remarks, show genuine care and concern by listening, and follow through on promises. The nurse should also respect the client’s belongings and personal space.
a. A 44-year-old with chest pain and diaphoresis
b. A 50-year-old with chest trauma and absent breath sounds
c. A 62-year-old with a simple fracture of the left arm
d. A 79-year-old with a temperature of 104° F
A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.
a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom.
b. Use two identifiers before each intervention and before mediation administration.
c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.
d. Search the belongings of clients with altered mental status to gain essential medical information.
e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections.
To ensure client and staff safety, nurses should use two identifiers per The Joint Commission’s National Patient Safety Goals; follow the hospital’s security plan, including de-escalation strategies for people who demonstrate aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses should also use standard fall prevention interventions, including leaving stretchers in the lowest position with rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders.
a. Mechanism of injury
b. Diagnostic test results
d. List of home medications
e. Isolation precautions
Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the client’s situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, interventions provided, and response to those interventions.
a. Foley catheterization
b. Needle decompression
c. Initiating IV fluids
d. Splinting open fractures
e. Endotracheal intubation
f. Removing wet clothing
g. Laceration repair
The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spine control; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.
a. Psychiatric crisis nurse – Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis
b. Forensic nurse examiner – Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources
c. Triage nurse – Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs
d. Emergency medical technician – Obtains client histories, collects evidence, and offers counseling and follow-up care for victims of rape, child abuse, and domestic violence
e. Paramedic – Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration
The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client’s behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.
a. Provide medical supplies to the family.
b. Consult a home health agency.
c. Encourage participation in community activities.
d. Screen for depression and suicide.
e. Complete a functional assessment.
Due to the high rate of suicide among older adults, a nurse should assess all older adults for depression and suicide. The nurse should also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits.