Chapter 45: Care of Patients with Trauma or Shock My Nursing Test Banks

Chapter 45: Care of Patients with Trauma or Shock

MULTIPLE CHOICE

1. A diving accident occurs at the community pool and the victim is conscious and in pain. Which intervention is most appropriate pending the arrival of emergency medical personnel?

a.

Pulled up onto the side of the pool

b.

Pulled to the shallow end and covered with a towel

c.

Left in the pool and supported by a large float

d.

Supported in the pool while CPR is attempted

ANS: C

Care should be taken to avoid movement of the patient and increasing injury to the spinal cord. Leaving the patient in the pool and supporting the patient on a float will not increase a possible spinal injury. Pulling the patient may cause further injury to the spine. CPR is not indicated as the patient is not experiencing cardiopulmonary arrest.

DIF: Cognitive Level: Application REF: 1019 OBJ: 2 (theory)

TOP: Diving Injury: First Aid KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

2. A drowning victim is brought to shore and is semiconscious and breathing. The most appropriate initial action of the camp counselor will require that the victim will be placed in what position?

a.

Supine to receive CPR

b.

Supine with knees flexed

c.

On the side in recovery position

d.

Prone with head turned to side

ANS: C

The patient who is breathing should be placed in the recovery position to allow the patient to vomit out water without danger of aspiration. CPR is not indicated as the patient is not experiencing the absence of cardiopulmonary activity. Lying supine or prone will not prevent aspiration in the event of vomiting.

DIF: Cognitive Level: Comprehension REF: 1019 OBJ: 2 (theory)

TOP: Near-Drowning: Positioning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

3. The nurse using the memory prompt for emergency care, ABCDE, is aware that the E stands for:

a.

end.

b.

execute.

c.

expedite.

d.

expose.

ANS: D

The E stands for expose. This reminder is to assist the first responder to assess for other injuries that may be hidden under clothing.

DIF: Cognitive Level: Comprehension REF: 1022 OBJ: 2 (theory)

TOP: ABCDE Memory Prompt: Definition

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

4. The nurse is teaching a CPR class. During the class the nurse correctly includes which statement when discussing the Good Samaritan Law?

a.

The Good Samaritan Law protects only medical professionals from liability.

b.

The Good Samaritan Law protects all people from liability.

c.

The Good Samaritan Law limits the liability of a medical professional.

d.

The Good Samaritan Law defines specific situations in which no liability will occur.

ANS: B

The Good Samaritan Law is designed to protect passersby who render first aid so they will not be held liable for the outcome of emergency care. Individuals who choose to render care will be held to the standard consistent with their training. The law is not limited to medical personnel. It does not address limitations of liability. There is no definition of specific scenarios protected by the law.

DIF: Cognitive Level: Comprehension REF: 1020 OBJ: NA

TOP: Good Samaritan Law: Provisions KEY: Nursing Process Step: NA

MSC: NCLEX: NA

5. A victim of a knife fight is found lying in a parking lot with a loop of bowel protruding from an abdominal wound. The first responder should:

a.

attempt to replace the bowel back into the abdomen.

b.

wrap the victims shirt tightly around his body.

c.

cover the evisceration with a plastic shopping bag.

d.

assist the victim to flex his thighs against his abdomen.

ANS: C

Covering evisceration with a nonadhesive covering will keep the bowel moist. Attempts to return the bowel into the abdomen may result in further injury. Tightly wrapping the shirt around the body may compromise circulation. Flexion of the thighs onto the abdomen may compress and cause further damage to the bowel.

DIF: Cognitive Level: Application REF: 1025 OBJ: 2 (theory)

TOP: Evisceration: First Aid KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

6. A worker in a department store fell through a plate glass window, causing a deep laceration on the right mid-thigh that is pumping bright red arterial blood. The best initial intervention of the first responder should be to:

a.

elevate the leg.

b.

bunch up the workers shirt and press it against the wound.

c.

press the palm of hand in the groin to compress the femoral artery.

d.

tie the workers belt tightly around his upper thigh to stop bleeding.

ANS: C

Compression of the artery is the best initial move, followed by compression with dressing and elevation.

DIF: Cognitive Level: Application REF: 1024 OBJ: 2 (theory)

TOP: Arterial Bleed: Intervention KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

7. The nurse cautions that, when cooling down a victim of heatstroke, one must be careful to prevent shivering because shivering can cause:

a.

a paralytic ileus.

b.

cardiac arrhythmias.

c.

an increase in temperature.

d.

a seizure.

ANS: C

Shivering is a homeostatic activity that generates heat and increases body temperature.

DIF: Cognitive Level: Analysis REF: 1027 OBJ: 3 (theory)

TOP: Heatstroke: Cooling Technique KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

8. The nurse reminds a group of CNAs that for a patient with an elevated temperature, the quickest and simplest technique to reduce the temperature is to:

a.

apply ice packs to the groin.

b.

bathe in tepid water.

c.

remove clothing and bed linen.

d.

give chilled drinks.

ANS: C

Removing the patients clothing and bed linen covering the patient is a quick, simple, and usually effective way to reduce temperature. The application of ice packs may result in excessive cooling and result in shivering, which acts to increase metabolic rate. Bathing in tepid water is effective but requires more time and interaction than simply removing clothing and bed linens. Chilled drinks will not adequately reduce the total body temperature.

DIF: Cognitive Level: Comprehension REF: 1027 OBJ: 3 (theory)

TOP: Increased Temperature: Initial Intervention

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

9. A spectator at the Little League playoffs in August in Texas faints in the sun-drenched stands. His face is flushed and his skin is hot to the touch. The first responder should assist him to:

a.

lie down on the bleacher seat.

b.

drink a large iced drink.

c.

be seated in the stands, shielded from the sun with an umbrella.

d.

a shady area, and sprinkle his clothing with water.

ANS: D

Remove the victim from the sun and cool by evaporation until emergency medical personnel arrive.

DIF: Cognitive Level: Application REF: 1027 OBJ: 3 (theory)

TOP: Heatstroke: First Aid KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

10. A student nurse is assisting with the care of a 50-year-old man who is being treated in the emergency department for hypothermia. The student asks the charge nurse why the patient is having his heart monitored. The nurses best explanation would be that the heart is being monitored because serious arrhythmias can be caused by:

a.

rapidly rising blood pressure from infusing IV fluids.

b.

adrenal output of epinephrine in response to cold stress.

c.

lactic acid being shunted from pooled blood in the extremities.

d.

vasodilation from the warming process.

ANS: C

Lactic acid in the blood that was pooled in the extremities while being exposed to cold will shunt back to the heart through systemic perfusion as the warming process becomes effective. The lactic acid can cause arrhythmias.

DIF: Cognitive Level: Application REF: 1027 OBJ: 3 (theory)

TOP: Hypothermia: Arrhythmias KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

11. The nurse assesses the frostbite on the victims hands and feet to be second-degree frostbite because the skin is:

a.

reddened and has hard white plaques.

b.

waxy and has sensory deficits.

c.

reddened and has blisters filled with milky fluid.

d.

waxy and has blisters filled with blood.

ANS: C

Frostbite is categorized by degree of injury, much like burns. The appearance of a first-degree injury includes reddened skin, swelling, waxy appearance, hard white plaques, and sensory deficit. Second-degree injury also has redness and swelling and formation of blisters filled with clear or milky fluid that form within 24 hours of injury. In third-degree injury, the blisters are blood filled followed by black eschar forming over several weeks. Fourth-degree injury involves full-thickness damage affecting muscles, tendons, and bone, resulting in tissue loss.

DIF: Cognitive Level: Application REF: 1027 OBJ: 3 (theory)

TOP: Frostbite: Staging KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

12. While attempting to revive a person brought to the emergency department with extreme hypothermia (rectal temperature of 94 F), unconscious, and shivering, the nurse is alarmed when assessment reveals that the patient has:

a.

reddened, cold ears.

b.

stopped shivering.

c.

blanched, hardened fingers.

d.

blisters on hands and arms.

ANS: B

Cessation of shivering indicates that the bodys homeostatic response to generate heat has ceased and the patients condition is deteriorating.

DIF: Cognitive Level: Analysis REF: 1027 OBJ: 3 (theory)

TOP: Hypothermia: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

13. An 80-year-old woman is brought to the emergency department by her daughter, who found the woman unconscious in her garage sitting in her car. A significant assessment of this patient as to cause of her condition would be:

a.

temperature, 97.6 F; pulse, 98; and blood pressure, 110/60.

b.

O2 saturation of 78%.

c.

cherry red mucous membranes.

d.

cold extremities.

ANS: C

The cherry red mucous membranes are classic signs of carbon monoxide poisoning; unfortunately, they are very late signs.

DIF: Cognitive Level: Application REF: 1030 OBJ: 4 (theory)

TOP: Carbon Monoxide Poisoning: Significant Assessment

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

14. A restaurant patron sitting at the next table begins to choke. The patron yells, Im choking! I cant breathe! The first responder should:

a.

initiate the Heimlich maneuver immediately.

b.

strike the victim sharply between the scapulae.

c.

encourage him to keep coughing and deep breathe.

d.

offer him a small sip of fluid.

ANS: C

Because the victim can cough and speak, the airway is not compromised. Support his efforts to clear the foreign matter by coughing. The Heimlich maneuver can be initiated at such a time that the victims airway becomes occluded.

DIF: Cognitive Level: Application REF: 1025 OBJ: 7 (theory)

TOP: Choking: Intervention KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

15. A deliveryman comes to the emergency department with dog bites on his legs. He states that the dog ran away after the attack and could not be identified. After treatment of the bites, the patient should immediately:

a.

notify Animal Control.

b.

receive immune globulin for passive immunity.

c.

receive the first of five rabies vaccination injections to be continued over the next several weeks.

d.

go home and elevate his legs.

ANS: B

The administration of immune globulin will build up his immediate defenses. As a deliveryman, he would be considered to be in a high-risk group for animal bites and should be advised to acquire the vaccine, but the vaccine will not be of any use to him at this point.

DIF: Cognitive Level: Application REF: 1030 OBJ: 5 (theory)

TOP: Animal Bite: Prophylaxis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

16. The first responder to an automobile accident finds a victim with a sucking chest wound. The responder should:

a.

tightly bind the injury with a folded magazine and the patients belt.

b.

place a plastic sandwich bag over the wound and tape on three sides to make a flutter dressing.

c.

turn the patient to the affected side and instruct the patient to deep breathe.

d.

place the patients hand over the wound and tell the patient to press down.

ANS: B

The flutter dressing will allow the air to leave the pleural space, but not allow any more air in. The collapsed lung will begin to reexpand.

DIF: Cognitive Level: Analysis REF: 1025 OBJ: 2 (theory)

TOP: Sucking Chest Wound: First Aid Intervention

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

17. The nurse has arrived on the scene of an accident. The victim is conscious and has a large bleeding laceration on his thigh. After the nurse uses an available towel to provide compression to the wound, what action should be performed next?

a.

The nurse should turn the patient to his left side.

b.

The nurse should elevate the patients affected leg.

c.

The nurse should bend the affected leg at the knee.

d.

The nurse should encourage the patient to perform leg pump exercises.

ANS: B

Once the bleeding has stopped, a compression dressing and bulky bandage are applied and left in place to prevent disturbing clots gently. Elevating and immobilizing the injured part will help to control bleeding.

DIF: Cognitive Level: Application REF: 1024 OBJ: 1 (theory)

TOP: Control of Bleeding: Safety Alert KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

18. The nurse is reviewing the physicians notes on a patients chart. The nurse notes that the patient demonstrated Cullens sign. The nurse correctly recognizes that this patient most likely had which manifestation?

a.

Sharp flank pain

b.

Pain in the upper right quadrant of the abdomen

c.

Pain with inspiration

d.

A bluish tinge around the umbilicus

ANS: D

Cullens sign refers to a bluish tinge around the umbilicus. It may be noted in the presence of internal abdominal hemorrhage.

DIF: Cognitive Level: Comprehension REF: 1025-1026 OBJ: 3 (theory)

TOP: Abdominal Trauma KEY: Nursing Process Step: Diagnosis

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

19. The nurse is caring for a conscious patient who has symptoms consistent with hypoglycemia. After a serum glucose reading supports this diagnosis, which substance is preferred to initially increase the patients glucose level?

a.

Carbonated cola beverage

b.

A teaspoon of white sugar

c.

A glass of milk

d.

Intravenous glucose

ANS: C

When the patient is conscious, an oral glucose-containing substance is suggested. A glass of milk, glucose tablets, or hard candy is preferred.

DIF: Cognitive Level: Application REF: 1026 OBJ: 1 (theory)

TOP: Hypoglycemia: Treatment KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

20. The nurse recognizes indications of respiratory distress, which include: (Select all that apply.)

a.

gasping.

b.

wheezing.

c.

stridor.

d.

choking.

e.

stupor.

ANS: A, B, C, D

All options except stupor are indicators of respiratory distress.

DIF: Cognitive Level: Knowledge REF: 1023 OBJ: 6 (theory)

TOP: Signs of Respiratory Distress: Assessment

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

21. The nurse stresses that moving a victim of an automobile accident is necessary if there is: (Select all that apply.)

a.

pooled gasoline.

b.

oncoming traffic.

c.

submersion in snow.

d.

request from the victim to be moved.

e.

exposure to hot pavement.

ANS: A, B, C, E

A victim request to be moved is not a valid reason to do so if the victim is safe.

DIF: Cognitive Level: Comprehension REF: 1024 OBJ: 2 (theory)

TOP: Moving an Accident Victim: Rationale

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

22. The nurse counsels a group of young track athletes that to prevent heatstroke they should: (Select all that apply.)

a.

drink plenty of fluids with high sugar content.

b.

wear lightweight, loose clothing.

c.

practice in the early morning.

d.

rest frequently in cool places.

e.

wear dark-colored clothing to block sun rays.

ANS: B, C, D

Liquids should be nonalcoholic, noncaffeinated, and low sugar as liquids with alcohol, caffeine, and sugar increase dehydration. Light-colored clothing should be worn as dark colors absorb heat.

DIF: Cognitive Level: Comprehension REF: 1026 OBJ: 3 (theory)

TOP: Heatstroke: Prevention KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

23. The home health nurse in Wyoming gives instruction to an 80-year-old patient in the prevention of hypothermia when outdoors for long periods of time, which includes: (Select all that apply.)

a.

wearing multiple layers of clothing.

b.

wearing a snug-fitting hat.

c.

moving about briskly.

d.

drinking warm fluids from thermos.

e.

wearing gloves and earmuffs.

ANS: A, B, C, D, E

All options listed are helpful in the prevention of hypothermia.

DIF: Cognitive Level: Application REF: 1027 OBJ: 3 (theory)

TOP: Hypothermia: Prevention KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

24. The nurse explains that the older adult is prone to hypothermia because the older adult: (Select all that apply.)

a.

eats less.

b.

has more subcutaneous fat.

c.

has lower metabolism.

d.

has atherosclerosis.

e.

is less active.

ANS: A, C, D, E

The older adult has less subcutaneous fat.

DIF: Cognitive Level: Application REF: 1027 OBJ: 3 (theory)

TOP: Hypothermia: Older Adult KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

25. The nurse is aware that the treatment for frostbite includes: (Select all that apply.)

a.

chafing the hands and fingers gently to reestablish circulation.

b.

immersion of hands and feet in warm water.

c.

wrapping hands in mitten-like dressings to retain warmth.

d.

administering opioids to reduce pain.

e.

elevating affected limbs.

ANS: A, B, E

Analgesia will be accomplished with nonsteroidal anti-inflammatory drugs as opioids decrease function and delay circulatory recovery. Fingers should be wrapped individually, not touching each other.

DIF: Cognitive Level: Application REF: 1027 OBJ: 3 (theory)

TOP: Frostbite: Treatment KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

26. The nurse is working with a group of hikers who range in age from 25 to 35 years. They have been instructed on ways to prevent heatstroke. Which drink selection by a participant indicates the need for further education? (Select all that apply.)

a.

Clear carbonated soda

b.

Diet caffeinated cola

c.

Water

d.

Beer

e.

Sugar-sweetened energy drinks

ANS: A, B, D, E

To aid in the prevention of heatstroke, the hiker should drink plenty of fluids that are nonalcoholic, caffeine free, and low in sugar content as the wrong fluids can increase fluid loss. Clear carbonated soda and sweetened energy drinks are high in sugar. Diet cola contains caffeine.

DIF: Cognitive Level: Analysis REF: 1027 OBJ: 4 (theory)

TOP: Heatstroke: Prevention KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

27. The nurse is caring for a patient suspected of having heatstroke. Which findings are consistent with this diagnosis? (Select all that apply.)

a.

Bradycardia

b.

Tachycardia

c.

Irregular pulse patterns

d.

Visual disturbances

e.

Decreased urinary output

ANS: B, C, D, E

Heatstroke may cause an alteration in neurologic function. Other symptoms include visual disturbances, dizziness, nausea, and a weak, rapid, irregular pulse.

DIF: Cognitive Level: Application REF: 1026 OBJ: 4 (theory)

TOP: Heatstroke KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

28. When all five of the contestants in a custard pieeating contest arrive at the emergency department with vomiting and diarrhea, the nurse suspects that these signs are related to the contamination of the pies by _______________.

ANS:

Staphylococcus aureus

Staphylococcus aureus is the prime offender in contamination of custards, mayonnaise, and processed foods.

DIF: Cognitive Level: Comprehension REF: 1029 OBJ: 4 (theory)

TOP: Food Contamination: Staphylococcus aureus

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

MATCHING

The nurse differentiates the types of treatment that are appropriate for each type of shock. Match the type of shock with the type of treatment associated with it. (Use each option one time only.)

a.

Cardiogenic shock

b.

Hypovolemic shock

c.

Anaphylactic shock

d.

Neurogenic shock

e.

Insulin shock

29. Administration of epinephrine

30. Administration of vasoconstrictors

31. Administration of glucose orally or IV

32. Administration of fluids

33. Administration of inodilators

29. ANS: C DIF: Cognitive Level: Analysis REF: 1033

OBJ: 10 (theory) TOP: Types of Shock: Treatment KEY: Nursing Process Step: NA

MSC: NCLEX: NA

30. ANS: D DIF: Cognitive Level: Analysis REF: 1033

OBJ: 10 (theory) TOP: Types of Shock: Treatment KEY: Nursing Process Step: NA

MSC: NCLEX: NA

31. ANS: E DIF: Cognitive Level: Analysis REF: 1026

OBJ: 10 (theory) TOP: Types of Shock: Treatment KEY: Nursing Process Step: NA

MSC: NCLEX: NA

32. ANS: B DIF: Cognitive Level: Analysis REF: 1033

OBJ: 10 (theory) TOP: Types of Shock: Treatment KEY: Nursing Process Step: NA

MSC: NCLEX: NA

33. ANS: A DIF: Cognitive Level: Analysis REF: 1033

OBJ: 10 (theory) TOP: Types of Shock: Treatment KEY: Nursing Process Step: NA

MSC: NCLEX: NA

A neighbor is found slumped over the lawn mower and is unconscious. Arrange the interventions made by the first responder in appropriate order.

a.

Tell neighbors wife to call 911.

b.

Assess for heartbeat.

c.

Initiate cardiopulmonary resuscitation (CPR) if no respiration or circulation can be assessed.

d.

Assess for signs of breathing.

e.

Shake patient and call name to assess for level of consciousness (LOC).

34. Step 1

35. Step 2

36. Step 3

37. Step 4

38. Step 5

34. ANS: A DIF: Cognitive Level: Analysis REF: 1020

OBJ: 6 (theory) TOP: CPR: Preliminary Assessment

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

35. ANS: E DIF: Cognitive Level: Analysis REF: 1020

OBJ: 6 (theory) TOP: CPR: Preliminary Assessment

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

36. ANS: D DIF: Cognitive Level: Analysis REF: 1020

OBJ: 6 (theory) TOP: CPR: Preliminary Assessment

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

37. ANS: B DIF: Cognitive Level: Analysis REF: 1020

OBJ: 6 (theory) TOP: CPR: Preliminary Assessment

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

38. ANS: C DIF: Cognitive Level: Analysis REF: 1020

OBJ: 6 (theory) TOP: CPR: Preliminary Assessment

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

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