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.
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Correct Answer is D
Explanation
Accompany the client when ambulating. The nurse’s priority when caring for a client with alcohol use disorder and who is experiencing withdrawal symptoms is to prevent harm to the client. Physiologic manifestations of alcohol withdrawal syndrome include seizures, delirium tremens (DTs), and hallucinations. Therefore, ensuring the client’s safety is of the utmost importance. Accompanying the client when ambulating is the priority intervention as alcohol withdrawal may lead to ataxia, weakness, and dizziness which may lead to falls.
Choice A, placing the client in a private room, does not address the client’s physical needs.
Choice B, determining the client's level of disorientation, is something necessary to assess but not the priority.
Choice C, padding the side rails of the bed with towels, is not the priority intervention, and contributes little to the prevention of falls.
Correct Answer is D
Explanation
Difficulty maintaining sustained attention is a common manifestation of ADHD, according to the American Psychiatric Association and the CDC. This means that people with ADHD often have trouble focusing on tasks or activities for a long period of time, especially if they are boring or tedious.
The other choices are not manifestations of ADHD, but of other conditions or problems. Here are some reasons why:
Choice A: Difficulty using words in context is not a symptom of ADHD, but of a language disorder or a learning disability that affects communication skills.
Choice B: Difficulty performing self-grooming activities is not a symptom of ADHD, but of a physical disability, a mental health disorder, or a lack of motivation or self-care.
Choice C: Difficulty in acquiring reading skills is not a symptom of ADHD, but of dyslexia, which is a specific learning disability that affects reading and spelling.
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