Author Question: An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits ... (Read 77 times)

dalyningkenk · **on:** Jun 25, 2018

An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement?

a. Administer dexamethasone (Decadron).
b. Complete a mini-mental state examination.
c. Prepare the client for computed tomography of the brain.
d. Request a psychiatric consult.

Question 2

An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first?

a. Electrocardiogram (ECG)
b. Wound inspection
c. Creatinine kinase
d. Computed tomography of head

leahm14 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
The client is exhibiting signs of mountain sickness and high altitude cerebral edema (HACE). Dexamethasone (Decadron) reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not treat mountain sickness or HACE.

Answer to Question 2

ANS: A
Clients who survive an immediate lightning strike can have serious myocardial injury, which can be manifested by ECG and myocardial perfusion abnormalities. The nurse should prioritize the ECG. Other assessments should be completed but are not the priority.