Test bank for medical surgical nursing 6th edition by ignatavicius download

126 OBJ: Learning Outcome 1 TOP: Client Needs Category: Safe and Effective Care Environment Management of Care MSC: Integrated Process: Communication and Documentation 2.. 127 OBJ: Lear

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Test Bank for Medical Surgical Nursing 6th Edition by Ignatavicius

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

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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

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?

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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

MSC: Integrated Process: Nursing Process (Planning)

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

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a “What medications do you take?”

b “What year were you born?”

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c “Who is your contact person?”

d “Who is your primary health care provider?”

DIF: Cognitive Level: Application REF: N/A for Application and above

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?

a Administers a sedative medication

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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

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?

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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

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8 What would the emergency room nurse consider the major purpose of advanced cardiac life support (ACLS) certification?

a Learning the concepts of multitasking

b Becoming an expert in pediatric resuscitation

c Demonstrating competence in adult emergency

DIF: Cognitive Level: Knowledge REF: p 131

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MSC: Integrated Process: Teaching/Learning

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

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a Chest pain and diaphoresis

b Decreased breath sounds and coughing up yellow

secretions

c Left arm fracture

d Sore throat and a temperature of 102° F

ANS: C

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

Heart rate: 130 beats/min

Respiratory rate: 35/min

Bleeding from stabbing wound site

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a Assesses that the client is breathing adequately

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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

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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

DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 9

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MSC: Integrated Process: Nursing Process (Assessment)

14 When caring for a client who has a history of mental illness, which initial

nursing intervention is the most essential?

a Administering prescribed antianxiety drugs

b Decreasing the noise level and harsh lighting

c Removing phone cords and oxygen tubing from the

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a Ensures that the client has his or her call light

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

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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

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

survey for trauma? (Select all that apply.)

a Removal of wet clothing

b Splinting of open fractures

c Initiating IV fluids

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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

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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

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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

In what sequence would a client go through in the process of admission to

disposition in emergency care? Place the following steps in order of priority

a Client is transported to the medical-surgical floor

b Emergency room nurse gives a report on the client

c Paramedics arrive and start IV access

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d Nurse and other health care provider(s) perform

assessment

e Emergency medical technicians provide oxygen and

vital sign monitoring

f Laboratory technician obtains blood specimens

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6 Client is transported to the medical-surgical floor

1 ANS: E DIF: Cognitive Level: Application

REF: N/A for Application and above OBJ: Learning Outcome 10

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

2 ANS: C DIF: Cognitive Level: Application

3 ANS: D DIF: Cognitive Level: Application

4 ANS: F DIF: Cognitive Level: Application

5 ANS: B DIF: Cognitive Level: Application

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6 ANS: A DIF: Cognitive Level: Application

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