An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

Ask the client's friend to sign the informed consent since the client is unresponsive.

Notify the unit manager that an emergency court order is needed to allow surgery.

Carry on with surgical preparation of the client without a signed informed consent.

Continue to provide life support until a thorough search for a guardian is completed.

Answer and Explanation

The Correct Answer is C

Rationale

A. The client's friend may not legally be authorized to provide consent unless they hold medical power of attorney or legal guardianship for the client. Without documentation of such authority, the friend cannot sign the informed consent.

B. In emergency situations where a patient lacks decision-making capacity and there is no available legal guardian or next of kin to provide consent, hospitals may seek a court order to proceed with necessary treatment. However, this could delay emergency treatment.

C. This is based on the legal and ethical understanding that saving the patient's life takes precedence when immediate action is required and consent cannot be obtained.

D. Providing life support ensures that the client's immediate medical needs are addressed while efforts are made to locate a legal guardian. However, unavailability of next of kin should not delay definitive intervention

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Correct Answer is "{\"xRanges\":[389.5,439.5],\"yRanges\":[222,272]}"

Explanation

Site- the nose

Rationale

Rhinorrhea refers specifically to cerebrospinal fluid (CSF) rhinorrhea. This occurs when there is a leakage of CSF from the nose due to a fracture or injury to the skull base or surrounding structures, such as the cribriform plate.

CSF is a clear fluid that surrounds and cushions the brain and spinal cord. When there is a fracture or disruption in the skull base, CSF can leak out through the nasal passages. This condition is concerning because it can increase the risk of infection, such as meningitis, due to the direct communication between the central nervous system and the external environment through the nasal cavity.

A. Pickled olives. B. Fruits without sauce. C. Fresh or frozen vegetables without sauce. D. Cottage cheese. E. Canned soup.

Correct Answer is ["B","C"]

Explanation

Rationale

A. High in sodium due to pickling, which is not suitable for someone with hypertension.

B. Recommended because fresh fruits are low in sodium and high in potassium and other nutrients beneficial for managing blood pressure.

C. Recommended because they are low in sodium and rich in potassium, fiber, and nutrients that support cardiovascular health.

D. Cottage cheese is high in sodium and should be avoided or consumed in moderation.

E. Generally high in sodium, which should be limited or avoided in the diet of someone with hypertension.

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An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding? (Click the chosen location. To change, click on the new location.)

Correct Answer is "{\"xRanges\":[389.5,439.5],\"yRanges\":[222,272]}"

Explanation

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

Correct Answer is ["B","C"]

Explanation

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

A client admitted with pneumonia and on bedrest has not had the strength to perform self care. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPS. Which intervention should the home health nurse implement to ensure adequate care for all clients?

The nurse is assessing a 4-year-old client with eczema. The child's skin is dry and scaly, and the parent reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?