Chapter 34 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 34

Question 1

Type: MCSA

Which consideration will the nurse apply to the assessment of a patient who sustained penetrating trauma?

1. The extent of injury is related to the amount of energy transferred to the body tissues.

2. The amount of trauma sustained is related to the patients nutritional status before the injury.

3. If the patient was well hydrated at the time of injury, the extent will be diminished.

4. The primary determinant of injury is the arc traveled by the penetrating object.

Correct Answer: 1

Rationale 1: Penetrating trauma refers to injury sustained by the transmission of energy to body tissues from a moving object that interrupts skin integrity. Penetrating trauma produces actual tissue penetration and may also cause surrounding tissue deformation based on the energy transferred by the penetrating object.

Rationale 2: Pre-injury nutritional status is not a major factor in the amount of injury sustained.

Rationale 3: The patients fluid volume status has little to do with the amount of injury sustained.

Rationale 4: The physics of injury does include arc, direction of travel, diameter of the object, and other components, but these measures all relate to a more specific concept.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-3

Question 2

Type: MCSA

A 14-year-old white male is brought into the emergency room of an urban hospital with a penetrating wound caused by the accidental discharge of a gun. Which risk factor for this injury pattern would the nurse rank as the most influential?

1. Living in an urban area

2. Being white

3. Age

4. Gender

Correct Answer: 4

Rationale 1: Risk for unintentional injury is higher in rural areas. Rate for intentional injury is higher in urban areas.

Rationale 2: Native Americans have the highest death rates from unintentional injury.

Rationale 3: The risk of injury is highest for those 15 through 24.

Rationale 4: The risk for males is 2.5 times that of females, possibly because of male involvement in hazardous activities.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-1

Question 3

Type: MCSA

A patient was injured when the car he was driving hit a telephone pole. The patient is 6 feet tall and weighs 200 pounds. The car was traveling at approximately 25 miles per hour when it hit the 36 inch diameter wooden pole. The nurse would calculate which pounds per square inch of impact for this patient?

1. 833.3

2. 30,000

3. 5000

4. 12,245

Correct Answer: 3

Rationale 1: This is an incorrect measurement of this impact.

Rationale 2: This is an incorrect measurement of this impact.

Rationale 3: To calculate pounds per square inch of impact, the nurse would multiply the patients weight by the speed the car was traveling. For this situation, the calculation would be 200 lb 25 miles per hour, which means the patient sustained 5000 lb per square inch of impact.

Rationale 4: This is an incorrect measurement of this impact.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-2

Question 4

Type: MCSA

A patient brought into the emergency department with injuries sustained from a motor vehicle accident (MVA) is complaining of abdominal pain and begins to vomit. The nurse suspects injury from which most likely source?

1. Shearing

2. Deceleration

3. Compression

4. Acceleration

Correct Answer: 3

Rationale 1: Shearing occurs when two parts of the same structure move in opposite direction causing a tear. Shearing forces are common in MVAs, but this is not the most specific injury pattern for this patient.

Rationale 2: Deceleration is a decrease in the speed of velocity of a moving object. Deceleration injury is common in MVAs but is not the most specific injury in this situation.

Rationale 3: Compression is the process of being pressed or squeezed together with a resulting reduction in volume or size. The small bowel may be compressed between the vertebral column and the lower part of the steering wheel or an improperly placed seat belt. The bowel may rupture. Because the patient complained of abdominal pain and started to vomit, the nurse should suspect that the patient sustained a compression force injury.

Rationale 4: Acceleration is the increase in the rate of velocity or speed of a moving object and frequently occurs in MVAs. It is not the most specific injury pattern suggested by this scenario.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-2

Question 5

Type: MCSA

A teenage patient comes into the emergency department with an arrow lodged in his right lower thoracic region. Which nursing intervention is indicated?

1. Have the patient assume a left side lying position and pull on the arrow to remove it.

2. Slowly move the arrow to the left and right to attempt to dislodge it.

3. Stabilize the arrow by padding around the wound with gauze rolls.

4. Slowly rotate the arrow to attempt to dislodge it.

Correct Answer: 3

Rationale 1: The nurse should not pull on the arrow to attempt to remove it.

Rationale 2: The nurse should not move the arrow to the left and right since impaled objects may actually be controlling a hemorrhage from damaged structures and removal may precipitate exsanguination.

Rationale 3: If the offending weapon is impaled in the body, it is critical that the object be left in place and protected from further movement until definitive surgical intervention is available. Protective padding can be placed around the object, such as gauze rolls or abdominal pads. The nurse should stabilize the arrow by padding around the wound with gauze rolls.

Rationale 4: The nurse should not rotate the arrow since impaled objects may actually be controlling a hemorrhage from damaged structures and removal may precipitate exsanguination.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-3

Question 6

Type: MCSA

A patient with a gunshot wound to the knee is complaining of groin and hip pain. The nurse realizes that this patients pain might be because of which effect?

1. Cavitation

2. Tumble

3. Yaw

4. Blast effect

Correct Answer: 4

Rationale 1: Cavitation is the formation of a cavity caused by the force of the missile. It would be unlikely that cavitation would extend from the knee to the groin.

Rationale 2: Tumble is the action of forward rotation around the center of the missile or somersaulting. It would be unlikely that tumble alone would cause the groin pain.

Rationale 3: Yaw is the deviation of the missile either above or below the axis and may cause additional damage in the immediate are of the penetration.

Rationale 4: Tissue surrounding the missile tract is exposed to stretching, compressing, and shearing forces, which produce damage outside the direct path of the missile. Vessels, nerves, and other structures that are not directly damaged by the missile may be affected. The phenomenon of structure injury outside the direct missile path is referred to as blast effect.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-3

Question 7

Type: MCMA

The nurse is preparing to assess a motor vehicle accident victim who was lap and shoulder harness restrained. Due to the mechanism of injury the nurse will look for which most common injuries?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Lumbar spine fractures

2. Fractured patella

3. Pulmonary contusion

4. Flexion fracture of the cervical spine

5. Contusion of the small bowel

Correct Answer: 3,5

Rationale 1: Lumbar spine fractures are more commonly seen in lap belt only restrained drivers.

Rationale 2: Fractured patella is more commonly seen in unrestrained front seat passengers and fall injuries.

Rationale 3: Since the patient was restrained with a lap and shoulder harness, the nurse will most likely assess contusions underlying the location of the harness. Pulmonary contusions are an example of this injury.

Rationale 4: Flexion fracture of the cervical spine is most likely seen with an unrestrained driver.

Rationale 5: Since the patient was restrained with a lap and shoulder harness, the nurse will most likely assess contusions underlying the location of the harness. Small bowel contusions are an example of this injury.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-4

Question 8

Type: MCSA

A patient is brought into the emergency department after a car accident. Injuries include fractured left femur, tibia, and fibula with a mild contralateral head injury. The nurse would identify this injury pattern as consistent with which situation?

1. Unrestrained front seat passenger of a motor vehicle

2. Adult pedestrian hit by an automobile

3. Unrestrained driver of a motor vehicle

4. Child pedestrian hit by an automobile

Correct Answer: 2

Rationale 1: An unrestrained front seat passenger of a motor vehicle would have facial and lower extremity injuries.

Rationale 2: The injuries of a fractured femur, tibia, and fibula on the same side with a contralateral head injury is an expected injury pattern for an adult pedestrian hit by a motor vehicle.

Rationale 3: An unrestrained driver of a motor vehicle would have extensive injuries to the head, neck, thorax, abdomen, and lower extremities.

Rationale 4: A child pedestrian would have a chest injury in addition to the limb and head injury.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-4

Question 9

Type: MCSA

A pregnant patient in her third trimester has been involved in a motor vehicle accident. Which intervention should the nurse implement to treat the patients symptoms of hypotension?

1. Turn the patient to the right lateral position.

2. Turn the patient to the left lateral position.

3. Place the patient in Trendelenburgs position.

4. Place the patient in the supine position.

Correct Answer: 2

Rationale 1: The right lateral position would allow compromise of the inferior vena cava.

Rationale 2: Placing the patient in the left lateral position shifts the uterus to the left, thus, preventing the heavy uterus from compressing the inferior vena cava against the spinal column and decreasing venous return and preload.

Rationale 3: Placing the patient in Trendelenburgs position would compress the inferior vena cava and may compromise the patients ability to breath.

Rationale 4: Supine positioning can result in development of inferior vena cava syndrome, making it difficult to treat hypotension.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-4

Question 10

Type: MCSA

A 78-year-old patient with a history of hypertension being treated with daily doses of metoprolol (Lopressor) was involved in a motor vehicle accident. The nurse would provide care based on absence of which compensation for hypovolemic shock?

1. A drop in blood pressure

2. A drop in urine output

3. A decrease in level of consciousness

4. Tachycardia

Correct Answer: 4

Rationale 1: A drop in blood pressure would likely occur.

Rationale 2: The patient is likely to manifest a drop in urine output if hypovolemic shock occurs.

Rationale 3: Treatment with metoprolol will not prevent decrease in LOC if hypovolemic shock occurs.

Rationale 4: Tachycardia usually associated with hypovolemic shock is prevented by the medication, a beta blocker, which the patient is taking daily.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-4

Question 11

Type: MCMA

The nurse is assessing a patient injured in a fall from a tree. During the assessment the patient suddenly loses consciousness. Which interventions should the nurse use to protect this patients airway?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Hyperextend the neck.

2. Suction the patient.

3. Stabilize the neck.

4. Remove the tape the paramedics used to tape the patients head to the backboard.

5. Pull up on the patients lower jaw.

Correct Answer: 2,3,5

Rationale 1: The nurse should avoid hyperextension of the neck in patients who may have sustained a cervical spine injury. Falling from a tree is a mechanism of injury that suggests cervical spine injury may be possible.

Rationale 2: Suctioning the patient to clear the airway is a standard resuscitation intervention.

Rationale 3: The nurse must attend to neck stabilization at all times even when opening the airway.

Rationale 4: This tape is used for stabilization and should not be removed until the cervical spine is cleared of injury.

Rationale 5: Using the jaw thrust maneuver or pulling up on the lower jaw will help open the airway without moving the head on the neck.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-5

Question 12

Type: MCSA

The nurse has adequately managed a patients airway, breathing, and circulation. What is the next nursing action?

1. Assess level of consciousness.

2. Administer prophylactic tetanus toxoid as prescribed.

3. Auscultate heart sounds.

4. Assess the chest for paradoxical movements.

Correct Answer: 1

Rationale 1: The nurse should assess the patients neurological status or level of consciousness as the next step.

Rationale 2: Administering prophylactic tetanus toxoid and transferring the patient should happen after the assessment is complete.

Rationale 3: Auscultation of heart sounds is part of the secondary survey, which is done after the primary survey. The primary survey is not yet complete.

Rationale 4: Assessment for paradoxical movement of the chest is part of the secondary survey, which occurs after the primary survey. The primary survey is not yet completed.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-5

Question 13

Type: MCSA

While conducting the secondary survey of a patient admitted with multiple traumas, the nurse assesses paralysis of the patients left lower leg. Which nursing intervention is indicated?

1. Move the patient to a semi-sitting position.

2. Support limb by placing it on a pillows.

3. Turn the patient to assess the back.

4. Immediately immobilize the patient.

Correct Answer: 4

Rationale 1: Moving the patient is not indicated.

Rationale 2: The nurse should not move the limb in order to place it on pillows.

Rationale 3: Turning the patient is not indicated at this time.

Rationale 4: If during the complete neurological examination the nurse assesses any evidence of paralysis or paresis, prompt immediate immobilization of the entire patient should occur if not already done. The nurse should remember that during the secondary survey, the patient may manifest findings requiring return to interventions recognized as part of the primary survey.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-5

Question 14

Type: MCMA

A patient who sustained a chest injury has developed tracheal deviation to the left side. The nurse would provide which equipment for immediate treatment of this complication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A venous cut down tray

2. A chest tube

3. Intubation equipment

4. 14 gauge needle

Correct Answer: 3

Rationale 1: Suctioning will not manage this complication. Suctioning may be necessary after the management procedure is completed.

Rationale 2: Accessing a vein with a venous cut down tray will not resolve this complication.

Rationale 3: Tracheal deviation indicates development of a tension pneumothorax. The treatment for this complication includes decompression with a chest tube. A nurse should anticipate this and prepare a chest tube insertion tray.

Rationale 4: Intubation will not resolve this complication but may be required after the treatment procedure is completed.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-7

Question 15

Type: MCMA

The nurse is providing care to a farmworker who was pinned against a steel gate by a horse. Deformation of the patients pelvis and femurs is obvious, but little blood is present on the patients clothing. Initial blood pressure is 110/68 mm Hg. What nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Initiate intravenous access with a 16 gauge catheter.

2. Start fluid resuscitation with normal saline.

3. Prepare to administer vasopressor medication.

4. Turn the patient to assess for injuries to the back.

5. Prepare to insert a chest tube.

Correct Answer: 1,2

Rationale 1: This patients mechanism of injury and assessment indicates potential for femur and pelvic fractures, which can result in massive blood loss. The normal blood pressure may be related to pain and adrenaline release. Venous access with large gauge catheters is essential.

Rationale 2: This patient may be bleeding internally. Fluid resuscitation is indicated.

Rationale 3: Vasopressor medications are not useful until fluid volume is restored.

Rationale 4: This patient should not be moved until further assessment is conducted.

Rationale 5: Nothing in the patients assessment indicates need for a chest tube at this point. The nurse should continue to assess airway and breathing.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-6

Question 16

Type: MCMA

A 24-year-old woman was critically injured when hit by a car while she was walking to work. Emergency department staff has been working for one hour to stabilize her. Which parameters would the nurse evaluate as indicating the patient is adequately fluid resuscitated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Her core temperature is 98.2F.

2. Her mean arterial pressure has been in the 70s for the last 30 minutes.

3. She is no longer tachycardic.

4. Her last lactate level was 2.0 mMol/L.

5. Her last sublingual capnography reading was 74.

Correct Answer: 2,3,4

Rationale 1: Temperature is not evaluated as an end point of trauma resuscitation.

Rationale 2: MAP above 70 is an end point for trauma resuscitation.

Rationale 3: HR less than 100 bpm is an end point for trauma resuscitation.

Rationale 4: Lactate levels less than 2.2 mMol/L is an end point for trauma resuscitation.

Rationale 5: Sublingual capnography level should be less than 70.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 34-6

Question 17

Type: MCSA

A patient being treated for hypovolemia because of traumatic injuries has a blood pressure of 110/60 mmHg. What should the nurse do to validate this clinical finding?

1. Assess neck veins and urine output.

2. Measure oxygen saturation with oximetry.

3. Check serum potassium and sodium levels.

4. Check for pupillary constriction.

Correct Answer: 1

Rationale 1: Peripheral vasoconstriction, a compensatory mechanism, may artificially elevate blood pressure readings even though central arterial pressures are low in the patient being treated for hypovolemia because of traumatic injuries. To prevent misdiagnosis by focusing on one symptom while ignoring others, the nurse should monitor the trauma patients blood pressure and at the same time assess neck veins, level of consciousness, and urine output.

Rationale 2: The oxygen saturation measurement through oximetry will not provide information about the patients fluid status.

Rationale 3: Electrolyte levels will not provide adequate information about the patients fluid volume status.

Rationale 4: Pupillary constriction is not a good indicator of fluid volume and may have been affected by medications administered during resuscitation.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-6

Question 18

Type: MCSA

It is suspected that a patient who sustained multiple traumas is developing cardiac tamponade. Which nursing assessment finding would help to support this tentative diagnosis?

1. Flat neck veins despite fluid resuscitation

2. Persistent hypotension

3. Atrial fibrillation per cardiac monitor

4. Bilateral basilar crackles

Correct Answer: 2

Rationale 1: Cardiac tamponade causes neck vein distention.

Rationale 2: Hypotension is part of Becks triad, which indicates development of cardiac tamponade.

Rationale 3: Atrial fibrillation is not an indicator of cardiac tamponade.

Rationale 4: Crackles in the lungs are not indicative of cardiac tamponade.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-7

Question 19

Type: MCSA

The nurse is caring for a patient who sustained a lacerated spleen from a motorcycle accident. Which complication is this patient most prone to experience because of the trauma?

1. Acute renal failure

2. Sepsis

3. Deep vein thrombosis

4. ARDS

Correct Answer: 1

Rationale 1: Abdominal trauma, specifically a lacerated spleen, makes the patient prone to developing the complication of acute renal failure, abdominal compartment syndrome, or disseminating intravascular coagulation.

Rationale 2: Sepsis is associated with an open pneumothorax and perforated intestine.

Rationale 3: Deep vein thrombosis is not associated with any particular organ system and can occur at any time with any health problem that restricts mobility or increases blood coagulation.

Rationale 4: ARDS is seen more often with thoracic traumatic injuries.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-7

Question 20

Type: MCSA

A patient is in the intensive care unit with a pulmonary contusion sustained from a motor vehicle accident. Which post-traumatic complication should the nurse focus on when providing care to this patient?

1. Abdominal compartment syndrome

2. Sepsis

3. ARDS

4. Acute renal failure

Correct Answer: 3

Rationale 1: Abdominal compartment syndrome is more common in patients with abdominal trauma.

Rationale 2: Sepsis is more common in patients with abdominal trauma or open wounds.

Rationale 3: The patient with a thoracic injury is prone to developing the post-traumatic complications of ARDS and DIC.

Rationale 4: Acute renal failure can occur with any massive trauma that involves blood loss, but is more common if injuries to the abdomen exist.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 34-8

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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