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.

Answer and Explanation

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 A

Explanation

The nurse should acknowledge and validate the client's feelings by saying, "It's okay to feel afraid. Let's talk about what you are afraid of." This response demonstrates empathy and encourages the client to express their concerns and feelings.

Choice B, "Your doctor is a great surgeon. You will be fine," dismisses the client's feelings and may increase their anxiety.

Choice C, "Don't worry. The important thing is you have now quit smoking," minimizes the seriousness of the procedure and the client's potential risks.

Choice D, "I understand your fears. I was a smoker also," shifts the focus from the client to the nurse and is not an effective way to provide emotional support for the client.

A. Initiate one-to-one nursing observation. B. Make a contract with the client for weight gain. C. Administer the Hamilton depression scale. D. Review the client's toxicology laboratory report.

Correct Answer is A

Explanation

initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.

Choice B, making a contract with the client for weight gain, is not an appropriate first action as it does not address the client's immediate safety concerns.

Choice C, administering the Hamilton depression scale, may be important to assess the client's depressive symptoms but is not the most urgent priority.

Choice D, reviewing the client's toxicology laboratory report, may be necessary for the overall assessment of the client, but safety comes first.

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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?

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