While at a public park, a nurse encounters a person immediately after a bee sting. The person's ...

The answer to question 1

ANS: D
The client's swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis.

The answer to question 2

ANS: B
The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9 saline solution, insertion of a urinary catheter, and aggressive interventions to cool the client, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this client's temperature or improve the client's symptoms. The client needs immediate medical treatment; therefore, rest and re-assessing in 15 minutes is inappropriate.

The answer to question 3

ANS: D, E
Due to the high rate of suicide among older adults, a nurse should assess all older adults for depression and suicide. The nurse should also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits.

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