Test bank for medical surgical nursing 6th edition by ignatavicius

126 OBJ: Learning Outcome 1 TOP: Client Needs Category: Safe and Effective Care Environment Management of Care MSC: Integrated Process: Communication and Documentation 2.. DIF: Cognitiv

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Test Bank for Medical Surgical Nursing 6th Edition by Ignatavicius

Chapter 10: Concepts of Emergency and Trauma Nursing

Test Bank

1 Which statement made by the nurse would indicate the need for further education?

a “Common reasons for emergency room admission

include headache and fever.”

b “Some clients use the emergency room as a clinic.”

c “The emergency room does not provide services to the

uninsured.”

d “The typical emergency room can appear chaotic.”

ANS: C

The emergency room must provide services to any client, regardless of her or his financial status All the other distractors are true in the emergency room

environment

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DIF: Cognitive Level: Comprehension REF: p 126

OBJ: Learning Outcome 1

TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care)

MSC: Integrated Process: Communication and Documentation

2 Which population would most likely go to the emergency room for treatment

of a temperature and a sore throat?

a Older adults

b Immunocompromised

c Pediatric

d Underinsured

ANS: D

The emergency room serves as an important safety net for clients who are ill or injured but lack access to basic health care Especially vulnerable populations

include the underinsured and uninsured

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3 Assessment findings reveal that a client has been raped Which health care team member will be most helpful in planning this client’s care in the

emergency room?

a Emergency medicine physician

b Case manager

c Forensic nurse examiner

d Psychiatric crisis nurse

ANS: C

All the other members of the health care team listed may be used in the

management of this client’s care However, the forensic nurse examiner is educated

to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault

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4 On admission to the emergency department, a client states that he feels like killing himself When planning this client’s care, it is most important for the nurse to coordinate with which member of the health care team?

a Case manager

b Forensic nurse examiner

c Physician

d Psychiatric crisis nurse

ANS: D

The psychiatric crisis nurse team interacts with clients and families in crisis This health care team member can offer valuable expertise to the emergency health care team, which also includes the case manager and physician

DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 2

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5 When taking the client’s medical history, what is the first question the nurse will ask to reduce the error potential in the emergency room?

a “What medications do you take?”

b “What year were you born?”

c “Who is your contact person?”

d “Who is your primary health care provider?”

ANS: A

A significant risk for all clients who enter the emergency room is the potential for medical errors or adverse events, especially those associated with medication

administration All the other distractors are questions asked in the assessment of the client, but are not as important as knowing what medications the client is taking

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control) MSC: Integrated Process: Nursing Process (Planning)

6 The emergency room nurse is assigned an older adult client who is confused and agitated Which intervention should be included in the nurse’s plan of care?

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a Administers a sedative medication

b Asks a family member to stay with the client

c Uses a Posey vest to prevent the client from climbing

out of the stretcher

d Places the client in front of the nurses’ station

ANS: B

Older adults who are confused are at increased risks for falls Fall prevention

includes measures such as siderails up, reorientation, call light in reach and, in some cases, asking the family member, significant other, or sitter to stay with the client to prevent falls

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control) MSC: Integrated Process: Nursing Process (Planning)

7 An emergency room nurse is transferring a client to the medical-surgical unit What is the most important core competency needed in this situation?

a Assessment

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b Communication

c Evaluation

d Multitasking

ANS: B

The emergency nurse needs to be able to assess, evaluate, and carry out

multitasking However, these competencies have already been carried out in the early phases of the emergency room admission When a client is ready to be

transferred out of the emergency room, though, communication with staff nurses from the inpatient units is essential This report should be a concise but

comprehensive report of the client’s emergency department experience

DIF: Cognitive Level: Knowledge REF: p 128

8 What would the emergency room nurse consider the major purpose of

advanced cardiac life support (ACLS) certification?

a Learning the concepts of multitasking

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b Becoming an expert in pediatric resuscitation

c Demonstrating competence in adult emergency

situations

d Demonstrating basic first aid skills

ANS: C

Certification marks successful completion of a particular course of study and

nursing specialty The ACLS course builds on basic cardiac life support (BCLS) content to include special resuscitation situations in the adult population

DIF: Cognitive Level: Knowledge REF: p 131

MSC: Integrated Process: Teaching/Learning

9 The emergency room nurse is caring for the following clients Which client does the nurse prioritize to see first?

a Blood pressure 100/60 mm Hg, right wrist painful and

swollen

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b Complaining of chest pain and diaphoresis

c Complaining of difficulty swallowing and nausea

d Respiratory rate of 28/min and temperature of 101° F

ANS: B

A client experiencing chest pain and diaphoresis would be classified as emergent and triaged immediately to a treatment room in the emergency department

MSC: Integrated Process: Nursing Process (Assessment)

10 The nurse needs to triage clients A client with which complaint would be considered as nonurgent?

a Chest pain and diaphoresis

b Decreased breath sounds and coughing up yellow

secretions

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c Left arm fracture

d Sore throat and a temperature of 102° F

ANS: C

A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration

11 A client has been injured in a stabbing incident The assessment reveals the following data:

Blood pressure: 80/60 mm Hg

Heart rate: 130 beats/min

Respiratory rate: 35/min

Bleeding from stabbing wound site

Client is lethargic

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Based on this assessment data, what would be the most appropriate level trauma center?

a Level I

b Level II

c Level III

d Level IV

ANS: A

The level I trauma center is able to provide a full continuum of care for all client areas Level II can provide care to most injured clients, but given the extent of his injuries, a level I center would be better if it is available Both levels III and IV can stabilize major injuries, but transport to a higher level center is preferred, when possible

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with an unresponsive client with an oxygen mask in place What will the nurse do first?

a Assesses that the client is breathing adequately

b Places a large-bore intravenous line

c Places the client on a cardiac monitor

d Takes a blood pressure reading

ANS: A

The highest priority intervention in the primary survey is to establish that the client

is breathing adequately Even though this client has an oxygen mask on, he may not

be breathing or may be breathing inadequately with the device in place

DIF: Cognitive Level: Knowledge REF: N/A for Application and above OBJ: Learning Outcome 8

13 A young man arrives at the emergency department (ED) following a motor vehicle collision He is not awake and is being bagged with a bag-valve-mask

by paramedics He has sustained obvious injuries to his head and face as well

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as an open right femur fracture that is bleeding profusely What will the nurse

do first?

a Splint the right lower extremity to decrease blood

loss

b Apply direct pressure to the open area on the right leg

c Assess for a patent airway

d Start two large-bore intravenous lines

ANS: C

The highest priority intervention in the primary survey is to establish a patent

airway Without an adequate airway to supply oxygen to the cells, a cerebral injury could progress to anoxic brain death After an airway is established, the

resuscitation may continue to B for breathing and C for circulation assessment

14 When caring for a client who has a history of mental illness, which initial nursing intervention is the most essential?

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a Administering prescribed antianxiety drugs

b Decreasing the noise level and harsh lighting

c Removing phone cords and oxygen tubing from the

room

d Setting firm behavioral limits

ANS: C

The first priority in caring for a mentally ill client is providing a safe environment All the other interventions can be used in providing a therapeutic environment However, they are not as imperative as the safety of the client and staff

15 A client with mental illness has just been admitted to the emergency room Which intervention is important for the nurse to carry out?

a Ensures that the client has his or her call light

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b Arranges for transport to a mental health facility

c Informs the client to stay in bed

d Reduces noise and harsh light in the room

ANS: D

Until the individual with mental illness can be admitted or transferred to an

appropriate psychiatric facility, the emergency nurse strives to create a therapeutic environment using a variety of assessment skills and intervention De-escalation techniques involve decreasing stimulation in the environment Once the client is comfortable, the nurse can then establish firm limits

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Environment) MSC: Integrated Process: Nursing Process (Implementation)

MULTIPLE RESPONSE

1 Which of the following interventions will be performed during the primary

survey for trauma? (Select all that apply.)

a Removal of wet clothing

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b Splinting of open fractures

c Initiating IV fluids

d Endotracheal intubation

e Foley catheterization

f Needle decompression

g Laceration repair

h Rectal examination

ANS: A, C, D, F

The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed The primary survey is

based on the standard mnemonic ABC, with an added D and E: A, airway and cervical

spine control; B, breathing; C, circulation; D, disability; E, exposure After completion

of the primary diagnostic studies, laboratory studies, and insertion of gastric and urinary tubes, the secondary survey, a complete head to toe assessment, can be carried out

DIF: Cognitive Level: Comprehension REF: N/A for Application and above OBJ: Learning Outcome 6

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MSC: Integrated Process: Nursing Process (Planning)

2 Which traumatic events are classified as penetrating trauma mechanism of

injury? (Select all that apply.)

a Assault with a baseball bat

b Blast effect from an exploding bomb

c Gunshot wound

d Stab wound to the neck

e Impact injuries sustained in a motor vehicle crash

ANS: C, D

The mechanism of injury (MOI) describes the manner in which the patient’s

traumatic event occurred Two of the most common injury-producing mechanisms are blunt trauma and penetrating trauma Penetrating trauma is caused by injury from sharp objects and projectiles Examples are wounds from knives, ice picks, and other comparable implements, as well as bullets or pellets Blunt trauma results from impact forces like those sustained in a motor vehicle crash, a fall, and an

assault with fists, kicks, or a baseball bat

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