A patient without health insurance comes into the Emergency department limping and dripping blood from a head wound. Which of the following should be done first for this patient?
Determine triage level and examine and stabilize as needed.
Give the patient information about facilities that specialize in treating people without health insurance.
Ask the patient to sign in and provide method of payment for services.
Transfer the patient to a hospital that specializes in traumatic brain injuries.
The Correct Answer is A
The nurse should determine the patient's triage level and examine and stabilize the patient as needed when caring for a patient without health insurance who is limping and dripping blood from a head wound in the Emergency department. This intervention is the priority because the patient could be at risk of life-threatening complications if their condition is left untreated. Giving the patient information about facilities that specialize in treating people without health insurance, choice B, and asking the patient to sign in and provide method of payment for services, choice C, may be necessary but are not the priority at this time. Transferring the patient to a hospital that specializes in traumatic brain injuries, choice D, may be necessary after stabilizing the patient, but it is not the priority at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
"The client learns to change negative thoughts into positive statements." This demonstrates the effective use of cognitive reframing, which involves changing negative thoughts into positive self-talk. This strategy can help to reduce stress and improve coping skills.
Choice A, "The client imagines being in a quiet, relaxing environment," is not an example of cognitive reframing, but rather an example of visualization, which can also be useful in reducing stress.
Choice B, "The client trains his mind to relax by using deep inner resources," is not an example of cognitive reframing, but rather an example of relaxation training.
Choice D, "The client learns the source of his stress by writing down daily events," is not an example of cognitive reframing, but rather an example of stress management through self-reflection.
Correct Answer is C
Explanation
Altered level of consciousness (LOC). Increased ICP can cause decreased LOC or changes in mental status, including confusion, agitation, or coma.
Options A, amnesia, and B, tachycardia, are not necessarily indicative of increased ICP, while option D, hypotension, is actually a sign of decreased ICP. Monitoring for elevated ICP is critical in patients with traumatic brain injury, and early recognition and intervention can be lifesaving. The nurse should report any changes in the patient's level of consciousness or other neurological symptoms to the provider immediately.
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