Chapter 67 My Nursing Test Banks

Osborn,_2e
Chapter 67

Question 1

Type: MCSA

A patient sustained multiple fractures and contusions when hit by a car while walking across the street. He says, How can I be hurt so badly? The car barely hit me. How should the nurse respond?

1. Your body absorbed a lot of energy from the moving car.

2. Because you are diabetic, your injuries are worse.

3. You probably dont remember how hard you were hit.

4. Because you are older, your injuries are worse.

Correct Answer: 1

Rationale 1: The nurse can respond with a simple statement that explains the transfer of energy to the patients body and the resulting injuries.

Rationale 2: The presence of diabetes does not explain the injuries in this situation.

Rationale 3: There is no indication that the patient sustained injury that would impair memory of the impact.

Rationale 4: The patients age does not explain the mechanism of injury.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 67-1

Question 2

Type: MCSA

A patient is admitted to the hospital with injuries from a motor vehicle collision. During the nurses initial assessment, the patient develops hypotension and severe jugular distention with a tracheal deviation. The nurse should act quickly to treat which probable condition?

1. Tension pneumothorax

2. Hemorrhage

3. Compensatory shock

4. Hypovolemic shock

Correct Answer: 1

Rationale 1: A tension pneumothorax is life-threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung.

Rationale 2: The patient would not have jugular vein distention with hemorrhage.

Rationale 3: The patient would not have jugular vein distention or tracheal deviation in the presence of compensatory shock.

Rationale 4: Hypovolemic shock is not characterized by jugular vein distention and tracheal deviation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-2

Question 3

Type: MCSA

A patient is admitted with a diagnosis of blunt trauma to the abdomen after a motor vehicle collision. What should the nurse assess first when the patient arrives in the emergency department?

1. Airway patency

2. Abdomen for external signs of injury

3. Cervical spine for tenderness

4. Capillary refill

Correct Answer: 1

Rationale 1: Assessment of the airway, including patency, is the highest priority in the trauma patient.

Rationale 2: This is not the priority assessment.

Rationale 3: The nurse should assess the cervical spine area after the initial ABC assessment.

Rationale 4: Capillary refill is an assessment of circulation but is not the highest priority.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-2

Question 4

Type: MCSA

A patient is brought to the emergency department with a penetrating wound to the neck. The patient is dyspneic and cyanotic, and has evidence of subcutaneous emphysema. Which intervention does the nurse prioritize?

1. Intubation

2. Notification of next of kin

3. X-ray of the cervical spine

4. Administration of an IV beta blocker

Correct Answer: 1

Rationale 1: Penetrating trauma to the neck is associated with a high degree of morbidity and mortality. Airway involvement includes dyspnea, cyanosis, subcutaneous emphysema, hoarseness, and air bubbling from the wound. The key is early identification of the need for intubation before the patient has no airway at all.

Rationale 2: The patient is critically injured and next of kin should be notified, but this is not the priority intervention.

Rationale 3: An X-ray evaluation of the cervical spine is important but does not hold the highest priority.

Rationale 4: Medication administration is not the highest priority for this patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 67-2

Question 5

Type: MCMA

A patient is brought to the emergency department after being involved in a motor vehicle crash. Which assessment would indicate to the nurse that FAST examination will likely be necessary?

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

Standard Text: Select all that apply.

1. Ecchymoses over the abdomen

2. Complaint of neck pain

3. Report of head-on crash in which the patient was the restrained driver

4. Lower leg lacerations and fractures

5. Complaints of chest wall tenderness

Correct Answer: 1,3,5

Rationale 1: Ecchymoses over the abdomen indicate the potential for internal bleeding. A FAST examination can determine the presence of free fluid in the chest or abdomen, which would signify bleeding and the need for rapid intervention.

Rationale 2: Neck pain etiology would not be diagnosed with a FAST examination.

Rationale 3: Seat belt injury can cause internal bleeding, which would be diagnosed with a FAST examination.

Rationale 4: A FAST examination does not assess injury of the lower extremities.

Rationale 5: A FAST examination can reveal the presence of free fluid within the chest, which would signify bleeding and the need for rapid intervention.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 67-3

Question 6

Type: MCSA

A patient is transported by ambulance with massive hemorrhage from a gunshot injury. Immediate transfusion of packed red blood cells is indicated. Which blood does the nurse anticipate transfusing?

1. Blood of the same type as the patients

2. Blood indicated by typing and cross-matching the patients blood

3. Type O blood

4. Type AB blood

Correct Answer: 3

Rationale 1: In emergent situations there is no time to determine the patients blood type.

Rationale 2: In emergent situations there is no time to type and cross-match the patients blood.

Rationale 3: Type O blood may be used if needed immediately.

Rationale 4: Without further testing it is not possible to determine that AB blood will be safe to transfuse into this patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 67-2

Question 7

Type: MCSA

A patient was an unrestrained driver in a frontal-impact motor vehicle collision. The nurse would expect which finding?

1. Unstable pelvic structure, causing severe pain on palpation

2. Neck muscle spasms caused by hyperextension of the neck

3. Paradoxical movement of the chest caused by multiple rib fractures

4. Unequal pulses in the lower extremities due to possible femur fracture

Correct Answer: 3

Rationale 1: Pelvic fractures are usually a result of frontal-impact collision when a seatbelt is worn.

Rationale 2: Hyperextension of the neck usually occurs in rear-end-impact collisions.

Rationale 3: If the driver has no seatbelt or the airbag does not deploy, the body might travel down and under the steering wheel or over the steering wheel, incurring injury at the bodys point of impact. Thus, rib fractures are common and can result in flailed chest injuries.

Rationale 4: Femur fracture is possible but is not as likely as another injury.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-1

Question 8

Type: MCSA

A child ran into the street and was struck by a car. Which finding, typical for this mechanism of injury, would the nurse anticipate assessing?

1. Lower extremity fracture caused by the wheels running over the child

2. Kidney injury due to the impact of the vehicle on the lower back

3. Chest or femur injuries where the bumper may have impacted the child

4. Liver injuries on the right side due to impact by the vehicle

Correct Answer: 3

Rationale 1: Multisystem trauma is likely, but specific lower extremity fracture is not the most common type of injury.

Rationale 2: Multisystem trauma is likely, but children are not generally struck in the back.

Rationale 3: Children tend to freeze and face the vehicle and therefore end up with more frontal injuries than adults. So, depending on the height of the child and the height of the vehicle bumper, the impact occurs on the chest or femur.

Rationale 4: Multisystem trauma is likely, but children are not generally struck on the side.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-1

Question 9

Type: MCMA

A patient has been stabbed just below the left nipple. The nurse would assess for damage to which structures?

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

Standard Text: Select all that apply.

1. Lung

2. Heart

3. Spleen

4. Subclavian vein

5. Diaphragm

Correct Answer: 1,2,3,5

Rationale 1: Lung tissue is located in the damaged area.

Rationale 2: The heart could be damaged in this situation.

Rationale 3: The spleen is located in this area.

Rationale 4: The subclavian vein is probably out of reach of most common stabbing instruments.

Rationale 5: The diaphragm is located in the area of damage.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-1

Question 10

Type: MCSA

A gunshot wound victim is dumped in the parking lot of the emergency department (ED). What is the nurses priority action?

1. Notify security.

2. Initiate airway management with cervical spine immobilization.

3. Assess the patients level of consciousness.

4. Get a stretcher to bring the patient into the ED.

Correct Answer: 2

Rationale 1: The nurse should notify security, but this is not the priority action.

Rationale 2: In every situation assessment of the airway is the priority.

Rationale 3: Level of consciousness is important, but this assessment is not the immediate priority.

Rationale 4: The nurse should take another, more immediate action prior to transporting the patient into the ED.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 67-2

Question 11

Type: MCSA

A patient presents to the emergency department with brisk hemorrhage from a laceration on the lower leg. How should the nurse address the hemorrhage?

1. Tape ABD pads over the wound and reinforce them when they become saturated.

2. Apply direct manual pressure on the wound.

3. Pack ice directly on the wound to cause vasoconstriction.

4. Apply a tourniquet tight enough to stop all the external bleeding.

Correct Answer: 2

Rationale 1: Applying dressings without compression will not control the bleeding.

Rationale 2: Direct pressure is the best and easiest way to control external hemorrhage.

Rationale 3: Ice causes additional tissue damage.

Rationale 4: A tourniquet can cause crush injury to tissues and distal ischemia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 67-2

Question 12

Type: MCMA

A trauma patient who experienced blunt cardiac injury from a steering wheel should be assessed for cardiac tamponade. The nurse would assess for which clinical manifestations?

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

Standard Text: Select all that apply.

1. Neck vein distention

2. Presence of an S3 heart sound

3. Muffled heart sounds

4. Bounding pulse

5. Hypotension

Correct Answer: 1,3,5

Rationale 1: Neck vein distention is caused by elevation of central venous pressure.

Rationale 2: S3 heart sounds are related to fluid volume overload and are not expected with cardiac tamponade.

Rationale 3: The presence of blood in the pericardial sac results in muffling of the heart sounds.

Rationale 4: The heart is being squeezed by the hydraulic pressure of blood in the pericardial sac. The pulse will be diminished, not bounding.

Rationale 5: Hypotension results from decreased cardiac output.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-2

Question 13

Type: MCSA

A trauma patient is hemorrhaging from multiple gunshot wounds to the lower abdomen. The nurse provides care based on which priority nursing diagnosis (NDX)?

1. Ineffective Breathing related to shallow respirations

2. Fluid Volume Deficit related to effects of decreased renal perfusion

3. Impaired Ventilation related to airway obstruction

4. Ineffective Tissue Perfusion related to hypovolemia

Correct Answer: 4

Rationale 1: Pain from the wounds may cause splinting, which would affect breathing depth and rate, but this is not the priority NDX.

Rationale 2: The fluid volume deficit is not related to effects of decreased renal perfusion.

Rationale 3: There is no information to support airway obstruction as a related factor.

Rationale 4: When a patient is hemorrhaging, the tissues are not being perfused. Therefore, major organs such as the heart, brain, and lungs receive oxygenation, but other organs such as kidneys, intestines, and long muscles do not receive oxygenation and become ischemic.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 67-2

Question 14

Type: MCSA

The nurse should protect the trauma patients spinal cord. Which action should the nurse take?

1. Keep the patient flat and run a hand underneath to assess for posterior injuries.

2. Keep the patient supine until all diagnostic exams have been completed.

3. Keep the patient on a backboard for the first 24 hours.

4. Apply a rigid cervical collar and logroll the patient.

Correct Answer: 4

Rationale 1: The patient should be logrolled to allow for assessment for injuries to the back.

Rationale 2: Simply being supine does not protect the spine.

Rationale 3: The backboard can cause areas of pressure and reduce accessibility to injured areas. It is removed shortly after arrival at the ED.

Rationale 4: For trauma patients, approximately 55% of spinal injuries occur in the cervical region; a rigid cervical collar is a must to prevent further injury.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 67-4

Question 15

Type: MCSA

The nurse works in an emergency department in a town with a large proportion of retired persons. The nurse should consider which difference between older and younger adults as it pertains to emergency care?

1. Younger patients are at greater risk for rib fractures and flail chest because their chests are not as compliant as those of older adults.

2. Older patients have a greater capacity to increase their cardiac output on demand, and therefore can tolerate greater blood loss than younger patients.

3. Older patients have an increased incidence of subdural hematomas because their veins are more fragile and less elastic compared to those of younger patients.

4. The aorta is comparatively closer to the surface in younger adults, so they are at greater risk of tearing injuries.

Correct Answer: 3

Rationale 1: The thorax of the older patient is less compliant and therefore more susceptible to injury.

Rationale 2: Older patients are less able to increase cardiac output on demand due to decreased compliance and a limited degree of compensatory ability.

Rationale 3: Older patients have an increased incidence of subdural hematoma because of the increased dural vein fragility and loss of elasticity with age.

Rationale 4: The aorta of the elderly patient is inelastic and more vulnerable to injury.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 67-4

Question 16

Type: MCSA

The nurse would question aggressive fluid resuscitation as an early intervention for which patient?

1. The patient with a serious head injury from a fall

2. The patient whose hands were burned in a kitchen fire

3. The patient whose leg was severed in an industrial accident

4. The patient with an open abdominal wound from a car crash

Correct Answer: 4

Rationale 1: Current data suggest that aggressive fluid resuscitation may be useful for patients with head injuries.

Rationale 2: Aggressive fluid therapy is recognized as helpful for the patient with a thermal injury.

Rationale 3: Patients with isolated injury to an extremity may benefit from aggressive fluid therapy.

Rationale 4: For a patient who is actively bleeding, increasing the arterial blood pressure through administration of fluids can dislodge clots and interfere with the hemostatic mechanisms that manage clotting.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 67-2

Question 17

Type: MCMA

A patient was involved in an automobile accident in which the car left the road and hit a bridge. Which information provided by the paramedics would the nurse evaluate as important in understanding the mechanism of injury?

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

Standard Text: Select all that apply.

1. The speed of the vehicle was estimated at 60 miles per hour when it hit the bridge abutment.

2. The passenger cabin of the vehicle showed no signs of intrusion.

3. It was raining at the time of the crash.

4. Airbags in the car deployed.

5. The patient was wearing a seatbelt.

Correct Answer: 1,2,4,5

Rationale 1: Speed is important in determining mechanism of injury. The more slowly the energy force is applied, the less the energy transference.

Rationale 2: The condition of the portions of the car immediately surrounding the patient helps to determine possible injuries. For example, shards of metal around the patients seat would increase the likelihood of lacerations.

Rationale 3: Road conditions are not particularly pertinent to mechanism of injury.

Rationale 4: The amount of energy absorbed by protective devices such as airbags is important when considering mechanism of injury.

Rationale 5: The use of a seatbelt affects the mechanism of injury.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-1

Question 18

Type: MCMA

The patient was a restrained front seat passenger in a car crash. Which findings would the nurse evaluate as indicating possible internal injury from the seatbelt?

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

Standard Text: Select all that apply.

1. The patient is unconscious.

2. There are abrasions across the patients abdomen.

3. There is bruising across the patients chest.

4. The patient has ecchymosis across both knees.

5. The patient complains of hip pain.

Correct Answer: 2,3,5

Rationale 1: Unconsciousness could result from a variety of factors and is not specifically linked to wearing a seatbelt.

Rationale 2: Abrasions in the area where the seatbelt is worn may indicate internal injury.

Rationale 3: Bruising in any area where the seatbelt is worn may indicate internal injury.

Rationale 4: Bruising on the knees does not suggest internal damage from the seatbelt.

Rationale 5: The pelvis may experience an extreme energy load when the seatbelt is engaged. Hip pain may result and may indicate internal damage.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-1

Question 19

Type: MCSA

A patient was the restrained front seat passenger in a slow-speed automobile crash in which the car was struck in the middle of the passenger side. Where would the nurse look first for injuries in this patient?

1. Right head, arm, and hip

2. Left knee and ankle

3. Low back

4. There is no pattern to the potential injury.

Correct Answer: 1

Rationale 1: Patients generally receive the most injuries on the same side of the body as the vehicle impact.

Rationale 2: While injury to the left knee and ankle is possible, it is not the most likely site.

Rationale 3: While injury to the back is possible, it is not the most likely area.

Rationale 4: There is a possible pattern to the potential injuries.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-1

Question 20

Type: MCSA

The nurse is teaching a community education class on prevention of neck injury. Which information would the nurse include in this teaching?

1. Be certain the cars headrests are positioned correctly.

2. Wear a helmet when riding a motorcycle.

3. Ride only in the backseat of a car.

4. Disable side curtain airbags

Correct Answer: 1

Rationale 1: Proper positioning of headrests can help prevent neck injury.

Rationale 2: Helmets offer some protection for the skull but do not protect the neck.

Rationale 3: There is no evidence that riding in the backseat protects the neck.

Rationale 4: There is no evidence that side curtain airbags increase neck injury.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 67-1

Question 21

Type: FIB

A patient drove himself to the ED after falling from the roof of his one-story home. The nurse assesses the patient, considering that the fall was probably from about _____ feet.

Standard Text:

Correct Answer: 15

Rationale : The height of the roof line of a one-story house is usually about 15 feet. This is a significant distance because at heights above 15 feet, adults generally land on their feet. As distances below 15 feet, adults generally land in the position they were in as they fell. The injury pattern is different in different landing positions.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-1

Question 22

Type: MCMA

The nurse always treats multiple trauma victims as if a spine injury exists. Which assessment findings would the nurse evaluate as increasing the risk for the presence of a cervical spine injury?

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

Standard Text: Select all that apply.

1. The patient is confused and lethargic.

2. The patient has severe facial bruising and trauma.

3. The patient has severe open abdominal wounds.

4. The patient has an obvious depressed skull fracture.

5. The patient cannot follow commands.

Correct Answer: 1,2,4,5

Rationale 1: Patients who have an altered level of consciousness should be treated as if they have a cervical spine injury until proven otherwise.

Rationale 2: Patients who have had blunt trauma above the clavicle should be treated as if they have a cervical spine injury until proven otherwise.

Rationale 3: Severe open abdominal wounds do not increase the need for surveillance above the normal spinal precautions.

Rationale 4: Patients who have had blunt trauma above the clavicle should be treated as if they have a cervical spine injury until proven otherwise.

Rationale 5: Patients who have an altered level of consciousness should be treated as if they have a cervical spine injury until proven otherwise.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-2

Question 23

Type: MCMA

Which assessment findings would the nurse evaluate as supporting the diagnosis of flail chest?

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

Standard Text: Select all that apply.

1. An area of the chest wall is depressed when the patient inspires.

2. The patients cough is weak and causes obvious pain.

3. The patients chest x-ray reveals a broken rib.

4. The patients respirations are shallow.

5. The patient has a sucking chest wound.

Correct Answer: 1,2,4

Rationale 1: Flail chest is characterized by paradoxical chest movement.

Rationale 2: The instability in the chest wall results in an ineffective cough and pain when coughing.

Rationale 3: In flail chest, two or more ribs are broken in two or more places.

Rationale 4: Flail chest results in decreased tidal volume and decreased vital capacity.

Rationale 5: A sucking chest wound does not indicate flail chest.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-2

Question 24

Type: MCSA

A patient was hospitalized 36 hours ago after suffering multiple injuries, including flail chest on the right, in an explosion. This morning the patient has moist crackles in the right lung, and the sputum is streaked with blood. The nurse discusses these findings with the health care provider due to concern about the possibility of which injury?

1. Tension pneumothorax

2. Pulmonary contusion

3. Hemothorax

4. Pneumonia

Correct Answer: 2

Rationale 1: Moist crackles and bloody sputum are not the major findings associated with tension pneumothorax.

Rationale 2: The presence of flail chest increases the likelihood of pulmonary contusion. Moist crackles and bloody sputum are also associated with pulmonary contusion.

Rationale 3: Moist crackles and bloody sputum are not the major findings associated with hemothorax.

Rationale 4: Pneumonia may be manifested by moist crackles, but the sputum is generally not bloody. Flail chest 36 hours ago suggests a different pathology.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-2

Question 25

Type: MCMA

A patient was brought to the ED after falling from a tree. The patient has an open femur fracture and is bleeding from several lacerations across the abdomen and chest. The patient cannot remember what happened, the skin is cool and pale, and the femoral pulses are weak. Which nursing interventions are necessary?

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

Standard Text: Select all that apply.

1. Notify the health care provider immediately.

2. Start two large-bore IV lines if not already in place.

3. Apply pressure to bleeding wounds.

4. Apply a splint to the injured leg.

5. Place the patient on oxygen.

Correct Answer: 1,2,3,5

Rationale 1: This situation is emergent and immediate treatment, possibly surgical treatment, is necessary.

Rationale 2: The nurse should establish venous access if not already in place and should protect any venous access already established.

Rationale 3: External pressure is the best method of reducing bleeding from wounds.

Rationale 4: Application of a splint can wait until more important actions have been taken.

Rationale 5: The patient is in danger of hypovolemic shock from blood loss. The nurse should increase oxygen in the remaining blood.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 67-2

Question 26

Type: MCMA

A patient who sustained massive trauma has just lost consciousness. A cardiac monitor is initiated, and it reveals pulseless electrical activity. The team working on this patient would quickly assess for which conditions?

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

Standard Text: Select all that apply.

1. Loose electrical leads to the monitor

2. Cardiac tamponade

3. Tension pneumothorax

4. Profound hypovolemia

5. Spinal cord injury

Correct Answer: 2,3,4

Rationale 1: The patient has a rhythm but no pulse. The monitor is working correctly.

Rationale 2: Cardiac tamponade would cause standstill of the heart so no pulse would be generated, but electrical activity would still be present for a period of time.

Rationale 3: Tension pneumothorax can result in mediastinal shift, which would reduce or stop the flow of blood from the heart. This can make pulses very weak or absent. Electrical activity would be present for a period of time.

Rationale 4: If hypovolemia is profound, there is little venous return to the heart, resulting in very diminished cardiac output. Pulses would be very weak or absent. Electrical activity would be present for a period of time.

Rationale 5: Spinal cord injury would result in paralysis and might affect cardiac status but would not be characterized by pulseless electrical activity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-2

Question 27

Type: MCSA

A patient is admitted to the ED with massive trauma. What nursing intervention will help protect this patient from coagulopathy?

1. Start oxygen immediately.

2. Cover the patient with a blanket.

3. Place a pillow under the patients feet.

4. Use sterile technique for all invasive procedures.

Correct Answer: 2

Rationale 1: The patient does need immediate supplementary oxygen, but this will not protect against coagulopathy.

Rationale 2: Hypothermia increases the risk for coagulopathy and mortality.

Rationale 3: Elevating the patients feet is not significant to the prevention of coagulopathy.

Rationale 4: The nurse should use sterile technique for invasive procedures, but this will not protect against coagulopathy.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 67-2

Question 28

Type: MCMA

The mechanism of a patients injury suggests that the patient may have suffered a basilar skull fracture. The nurse would assess for which findings?

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

Standard Text: Select all that apply.

1. Battles sign

2. Hyphema

3. Raccoon eyes

4. Rigid extension of the forearms

5. Anasarca

Correct Answer: 1,3

Rationale 1: Battles sign is ecchymosis of the mastoid area and suggests basilar skull fracture.

Rationale 2: Hyphema is a collection of blood in the anterior chamber of the eye and is not indicative of basilar skull fracture.

Rationale 3: Raccoon eyes are ecchymoses over the orbit of the eyes and suggest basilar skull fracture.

Rationale 4: Rigid extension of the forearms is a posturing position indicating central nervous system damage, but is not specifically associated with basilar skull fracture.

Rationale 5: Anasarca is total body edema. It is not a sign of basilar skull fracture.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-2

Question 29

Type: MCMA

During the secondary survey it is discovered that a trauma patient has pelvic instability. Which nursing actions 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. Recheck stability every hour.

2. Monitor for bleeding.

3. Assist with wrapping a sheet around the pelvis.

4. Turn the patient every 2 hours, alternating sides and back.

5. Place the patient in high Fowlers position.

Correct Answer: 2,3

Rationale 1: Once pelvic instability is confirmed, no further stability checks are indicated.

Rationale 2: An unstable pelvis may cause damage to internal structures and bleeding. Urine should be monitored as well as skin color, skin temperature, and vital signs.

Rationale 3: A sheet can be wrapped around the pelvis to help stabilize it until further treatment is performed.

Rationale 4: An unstable pelvis can cause internal damage. The patient should not be turned until the pelvis is stabilized.

Rationale 5: High Fowlers position will place pressure on the unstable pelvis. The patient should be supine.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 67-2

Question 30

Type: FIB

The emergency services department of a hospital has adopted a policy of tertiary survey for all admitted trauma patients. The nurse understands that this survey will be done within ______ hours of admission.

Standard Text:

Correct Answer: 24

Rationale : A tertiary trauma survey (TTS) is performed within 24 hours of admission, after the initial resuscitation and operative intervention, to identify and catalog all injuries.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 67-3

Question 31

Type: MCSA

A 28-year-old woman is admitted to the ED with trauma sustained when a building collapsed. The nurse would question why which test was not ordered?

1. International normalized ratio (INR)

2. Blood alcohol

3. Pregnancy

4. Toxicology screen

Correct Answer: 3

Rationale 1: INR is monitored in patients taking warfarin. It would be unusual for a 28-year-old to be taking warfarin.

Rationale 2: Other assessment findings would have to be present for this test to be indicated.

Rationale 3: All female trauma patients of childbearing age should have a pregnancy test.

Rationale 4: Other assessment findings would have to be present for this test to be indicated.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 67-4

Question 32

Type: MCSA

A woman who is 14 weeks pregnant presents to the ED after falling down a flight of stairs. What should be the nurses first intervention?

1. Administer oxygen.

2. Attempt to locate fetal heart tones.

3. Start an IV with a large-bore catheter.

4. Position the patient on her right side.

Correct Answer: 1

Rationale 1: Oxygen consumption is increased in pregnancy. The pregnant trauma patient should always receive supplemental oxygen. This should be the first action according to the ABCs of assessment.

Rationale 2: It is important to assess fetal heart tones, but this is not the priority intervention.

Rationale 3: It may be necessary to secure venous access, but this is not the first priority.

Rationale 4: In more advanced pregnancy the uterus may compress the vena cava. In this situation the patient is placed on her left side.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 67-4

Question 33

Type: MCMA

The nurse providing care to a patient with multiple trauma is suspicious that intimate partner violence (IPV) may be the source of the injury. Which findings would increase the nurses concern?

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

Standard Text: Select all that apply.

1. This is the patients fourth ED visit this year for injuries.

2. The patients partner will not leave the room.

3. The partner is quiet and concerned.

4. The patient says, I fell because I am so clumsy.

5. The injuries do not match the history given.

Correct Answer: 1,2,4,5

Rationale 1: Frequent emergency department visits for injuries may indicate that violence is the cause.

Rationale 2: In IPV the partner may be concerned that the victim will tell if left unattended.

Rationale 3: In IPV, the partner often tries to answer questions for the victim.

Rationale 4: In IPV, the patient often blames herself for injuries.

Rationale 5: If injuries are inconsistent with the stated history, the nurse should suspect an attempt to hide the real cause.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-4

Question 34

Type: MCSA

Which assessment finding would the nurse evaluate as a possible indication that an older adult is being abused?

1. There are injuries in various states of healing over the patients trunk and extremities.

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