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Medical-Surgical Nursing

What Should the Nurse Do?

Medical-Surgical NursingWhat Should the Nurse Do?

What Should the Nurse Do?

1 .
A trauma patient in the emergency department was in a motor vehicle accident. They are unconscious and have a crush injury to the chest. Their vital signs are BP: 98/55; HR: 121; RR: 35; SpO2: 84 percent, and temperature: 95.9°F. How would the nurse assess this patient, and in what order would they address the patient’s vital signs?
2 .
A sixteen-year-old female patient enters the emergency department. The patient is having abdominal pain and fever, but she is alert and not disoriented. She is diagnosed with an ectopic pregnancy requiring an emergency D&C. How should the nurse obtain consent for this procedure? What elements are subjective and objective?
Jay K. arrives by ambulance to the emergency room complaining of nausea, vomiting, and abdominal pain. He works as a construction worker and mentions that he was exposed to various chemicals at a worksite earlier today. He reports no significant medical history other than occasional episodes of acid reflux. Vital signs are as follows: BP: 140/90 mm Hg; HR: 100 bpm, RR: 20 breaths/min; and temperature 99.2°F (37.3°C). John appears pale and diaphoretic. He expresses concern about the possibility of serious chemical exposure and is anxious about his health and ability to continue working.
3 .
What physical examination findings might indicate potential chemical exposure in this case?
4 .
What immediate interventions would you implement to address both the patient’s symptoms and concerns about potential chemical exposure?
5 .
A nurse goes into an emergency room bay to assess a patient who experienced a fall down the basement stairs. The patient is seen sitting in the chair, guarding her arm, with her partner standing in the corner, pacing. He is staring at her and does not maintain eye contact.
The nurse suspects domestic partner abuse. What should the nurse do?
Tonya W., a thirty-two-year-old female, arrives at the emergency department after being brought in by law enforcement due to concerns about her safety and the safety of others. She presents with agitation, disorganized speech, and paranoid delusions, expressing the belief that she is being followed by unknown individuals. Tonya W. has a history of schizophrenia and noncompliance with medication. On assessment, her vital signs are as follows: temperature: 98.6°F (37°C); BP: 140/90 mm Hg; HR: 110 bpm; RR: 20 breaths per minute; and oxygen saturation: 98 percent on room air. The nursing staff recognizes the potential for violence given Tonya W.'s behavior and history and implements measures for her safety and the safety of others in the emergency department.
6 .
What behavioral cues suggest that Tonya W. may pose a risk of violence in the emergency department?
7 .
How would you prioritize the interventions needed to address Tonya W.’s safety and the safety of others in the emergency department?
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