The nurse comes upon the scene of a multiple motor vehicle crash ...

[roselinechinyere27m]

The nurse comes upon the scene of a multiple motor vehicle crash and decides to stop and help because there are no emergency personnel present. The first priority for the nurse is to:
 
  1. Ensure that victims are removed from their cars.
  2. Quickly check all victims and perform CPR on the most injured.
  3. Assess the scene for safety to prevent more harm.
  4. Begin treating clients trapped in their cars.

Question 2

The family of a client in the ICU expresses their concern because their family member is confused and disoriented. The best explanation by the nurse is:
 
  1. This is expected in older clients with dementia.
  2. You can help us reverse this problem.
  3. You are visiting too much and disrupting care.
  4. The client might not recover from the confusion.

[rleezy04]

Answer to Question 1

Answer: 3

1. Trauma victims are not moved, because of the risk of spinal injury, unless a greater threat exists, such as the car is on fire.
2. The second priority of care is to triage the clients so that the medical personnel can be directed to the most gravely injured clients when they arrive.
3. In any emergency situation, the priority of the nurse is to assess the safety of the site to prevent injury to those administering care.
4. Once triage has been completed, the nurse can begin to give first aid to those who need it most.

Answer to Question 2

Answer: 2

1. Older clients with dementia are not the only clients who experience ICU psychosis. All clients in that environment are at risk without intervention by the nurse and family.
2. The nurse should explain the problem to the family and then teach the family strategies that they can use to help the client reduce and reverse confusion.
3. It is not possible for families to visit too much. They are critical to the well-being of the client.
4. Confusion in the ICU client is reversible with caring interventions by nurses and family.