Test bank for understanding the essentials of critical care nursing 2nd edition by perrin

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessme

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https://getbooksolutions.com/download/test-bank-for-Understanding the Essentials of Critical Care Nursing, 2nd Edition Test Bank – Perrin

1 Blunt trauma from internal forces caused by acceleration

2 Blunt trauma from external forces caused by deceleration

3 Penetrating trauma from external forces caused by deceleration

4 Penetrating trauma from internal forces caused by acceleration

Correct Answer: 2

Rationale 1: Internal forces refer to stress or strain created within the body, not

from outside forces Acceleration forces are when the increasing speed hits

someone who is stationary, such as a car hitting a person crossing the street

Rationale 2: Blunt trauma leaves the skin intact and damage to underlying tissue,

such as broken ribs External forces are created by the mass of the object and

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velocity of movement outside the body and the weight of the person being pushed forward after the car hit something Deceleration is the force that stops or

decreases the velocity of the moving victim, such as the chest hitting the steering wheel

Rationale 3: Penetrating wounds have an open wound and flail chests are intact at

the skin level

Rationale 4: Penetrating wounds have an open wound and flail chests are intact at

the skin level Internal forces refer to stress or strain created within the body, not from outside forces

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-1: Compare and contrast blunt and penetrating trauma

Question 2

Type: MCSA

Which patient sustained an open traumatic injury? A patient with:

1 A closed hip fracture that was caused by a fall

2 A gun shot wound without penetration of the bullet due to the bullet-proof vest

3 Near-drowning after falling through a frozen lake

4 Burns over 30% of the body from a house fire

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Rationale 1: This is an example of blunt trauma in which the skin is not broken,

but underlying tissue is damaged

Rationale 4: Burns over 30% of the body from a house fire is an example of an

open or penetrating wound in which the skin does not remain intact

Learning Outcome: 9-1: Compare and contrast blunt and penetrating trauma

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

Standard Text: Select all that apply

1 Ability to respond to painful stimuli

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2 Vital signs

3 Ability to respond to verbal command

4 Level of consciousness or unconsciousness

5 Oxygen saturation levels

Cognitive Level: Applying

Learning Outcome: 9-2: Describe elements of the primary and secondary

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1 Using a manual ventilation bag

2 Applying heated blankets

3 Using the jaw thrust maneuver

4 Assessing for history of asthma

Rationale 1: This action would be seen in step B–Breathing

Rationale 2: This action would be seen in step E–Environment/exposure

Rationale 3: Airway is covered under the A section Maintaining an open airway

is the first priority With a fracture or trauma to the neck, respirations may be altered or prevented by bone or tissue misalignment The jaw thrust maneuver is the correct way to open the airway for a cervical spine injury

Rationale 4: This action is performed in step H–Head-to-toe assessment/medical

history

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-2: Describe elements of the primary and secondary

assessments

Question 5

Type: MCMA

Which risk factors could lead to the development of airway failure if not

recognized while assessing the airway of a trauma patient?

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1 Chest wall injury

2 Displacement of the trachea (tracheal shift)

3 Aspiration of gastric contents

4 Foreign object occlusion of the throat/mouth

5 Swelling of soft tissue in the throat

Correct Answer: 2,3,4,5

Rationale 1: The chest wall injury would be a breathing survey assessment

because it focuses on thoracic trauma and the ability to ventilate and not obstruct the airway itself

Rationale 2: This can obstruct the airflow into or out of the lungs and cause airway

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Learning Outcome: 9-4: Discuss airway problems that may develop in a trauma

patient

Question 6

Type: MCSA

Which nursing assessment would have highest priority for early airway

management of a trauma patient?

1 Ask the patient to state his name

2 Assess increasing intracranial pressure (ICP) with facial fractures

3 Prepare for emergency tracheostomy

4 Perform a computerized tomography (CT) scan of tissues of the neck

Rationale 1: If the patient can state his name audibly then the airway is patent

Rationale 2: ICP monitoring might be needed but it is not the first priority of the

nurse for airway issues

Rationale 3: Emergency tracheostomy might be needed but it is still a second

action only if needed

Rationale 4: CT scanning might be needed but it is not the first priority of the

nurse for airway issues

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1 Pain with swallowing, coughing, or hemoptysis

2 Chest pain on inspiration

3 Popping sound (crepitus) in the throat when touching the skin by the trachea

4 Hoarseness when talking

Rationale 1: Each of these symptoms is an example of an airway maintenance

issue that can contribute to decreased airflow through the throat

Rationale 2: Chest pain is a breathing issue and not an airway problem

Rationale 3: Crepitus is noted with laryngeal fractures where air is escaping into

the subcutaneous tissue

Rationale 4: This is an example of an airway maintenance issue that can contribute

to decreased airflow through the throat

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1 Jugular vein distention

2 Symmetry of chest movement bilaterally

3 Chest movements that rise and fall with breathing effort

4 Respiratory rate, pattern, and effort

5 Peripheral skin coloring

Rationale 1: Jugular vein distention will increase when chest pressure rises with

displacement or fluid buildup in which the heart must work harder to circulate the blood and perfuse tissues that are hypoxic

Rationale 2: Chest movement symmetry will be assessed in the patient with

thoracic trauma

Rationale 3: Chest movements that rise and fall with breathing will be assessed in

the patient with thoracic trauma

Rationale 4: Respiratory rate, pattern, and effort will be assessed in the patient

with thoracic trauma

Rationale 5: Skin coloring is a circulation issue, not a breathing issue

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Learning Outcome: 9-5: Compare and contrast manifestations and management

of various types of thoracic trauma

Question 9

Type: MCSA

What will the nurse expect to assess in a patient with a tension pneumothorax?

1 Tracheal deviation to the unaffected side

2 Bilateral equal chest movement

3 Decreased muscular effort by chest muscles

4 Decreasing central venous pressure (CVP)

Rationale 1: As air accumulates on the pleural space with no place to escape, the

affected lung collapses and the resulting increase on intrathoracic pressure puts pressure on the trachea, which causes displacement to the unaffected side

Rationale 2: Normal breathing is bilaterally equal In a tension pneumothorax, one

or more areas of the lung tissue collapses and does not expand, therefore limiting the chest movement on that side Therefore, the movement is bilaterally unequal

Rationale 3: Increased muscle effort will be the response to decreasing lung

activity Extra muscles of the chest are called into place to try to increase the effort

to move the air within the lung tissues

Rationale 4: The CVP will increase to try to compensate for decreased pulmonary

perfusion from a decrease in the surface area for oxygen to be exchanged

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Client Need Sub: Physiological Adaptation

1 Provide oxygen 100% therapy through a nonrebreather mask

2 Restore the normal breathing pattern

3 Maintain a calm environment to decrease oxygen demands

4 Prevent sepsis

5 Maintain balanced hydration

Correct Answer: 1,2,4

Rationale 1: This will maximize available oxygen and allow the least respiratory

effort to increase perfusion to the greatest number of alveolar areas

Rationale 2: This will maximize available oxygen and allow the least respiratory

effort to increase perfusion to the greatest number of alveolar areas

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Rationale 3: Although remaining calm will decrease the oxygen demand, this is

not likely to occur when breathing difficulties create both physical and emotional stress Sedation may be needed if ventilation is in use and the patient is fighting the ventilator

Rationale 4: Preventing infection will allow the least respiratory effort to increase

perfusion in the greatest number of alveolar areas

Rationale 5: Although keeping the lung tissue moist is the ideal way to improve

cellular tissue exchange, it will not help if the problem is ineffective breathing The muscle effort or surface available to exchange is the problem that needs correction

Nursing/Integrated Concepts: Nursing Process: Planning

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Rationale 1: Tears in lung tissue and fluid accumulation in the pleural space will

decrease the gas exchange at the capillary level and/or at the airflow through the trachea

Rationale 2: Tears in lung tissue will decrease the gas exchange at the capillary

level and/or at the airflow through the trachea

Rationale 3: Displacement of underlying structures will decrease the gas exchange

at the capillary level and/or at the airflow through the trachea

Rationale 4: Displacement of underlying structures will decrease the gas exchange

at the capillary level and/or at the airflow through the trachea

Rationale 5: Bladder rupture would occur as a potential complication with

abdominal trauma and not as likely with a thoracic trauma

Nursing/Integrated Concepts: Nursing Process: Planning

Question 12

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Type: MCMA

Immediate interventions for a patient with a sucking chest wound include:

1 Administer pain medication

2 Continue to monitor pulse oximetry and respiratory characteristics

3 Prepare for emergency intubation

4 Prepare the patient for chest tube insertion

5 Apply a dressing that is taped on three sides

Rationale 1: Pain medication will allow an ease in the breathing effort and reduce

pain on insertion of the chest tube

Rationale 2: The nurse will continuously monitor pulse oximetry and respiratory

characteristics

Rationale 3: Emergency intubation may not be required because the patient can

still breathe The problem is not the effort to inhale or exhale air but to expand the collapsed lung tissue and prevent pressure buildup in the enclosed lung cavity

Rationale 4: Chest tubes are used to reinflate lung tissue by creating a negative

pressure

Rationale 5: A sucking chest wound sucks atmospheric air into the chest cavity

with each breath Closing off this air will decrease the collapse of lung tissue by using a dressing that allows air to leave the chest cavity (thus not taping all four sides) but decreasing the intake of air on inhalation

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1 Blood loss into the abdominal cavity can lead to hypovolemic shock

2 Septic shock is more common than hemorrhagic shock due to nosocomial infections

3 When fluids shift into the interstitial spaces, the loss of vascular fluids can lead to hypovolemic shock

4 Hemorrhagic shock symptoms include tachycardia, dyspnea, and

hypotension

Rationale 1: This is a true statement and does not need additional teaching Rationale 2: Septic shock is not more common than hemorrhagic shock

Hemorrhage is the most common cause for shock

Rationale 3: This is a true statement and does not need additional teaching Rationale 4: This is a true statement and does not need additional teaching Global Rationale:

Client Need: Health Promotion and Maintenance

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Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 9-6: Recognize the manifestations of hemorrhagic shock and

plan management strategies

1 Class I–treated with blood products

2 Class II–treated with isotonic fluids

3 Class III–treated with isotonic fluids and blood products

4 Class IV–treated with blood and fluids

Rationale 1: Class I–treated with colloid fluid resuscitation is incorrect and should

be treated with isotonic fluids

Rationale 2: This is the correct treatment for Class II shock

Rationale 3: This is the correct treatment for Class III shock

Rationale 4: This is the correct treatment for Class IV shock

Client Need Sub: Pharmacological and Parenteral Therapies

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Learning Outcome: 9-6: Recognize the manifestations of hemorrhagic shock and

plan management strategies

Rationale 1: This is a symptom of cardiac tamponade

Rationale 4: Jugular vein distention would increase, not decrease, with the

increasing backup of blood and the decreasing contractility from the limited

motion of the ventricles as fluid/blood builds up within the sac, limiting its ability

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Learning Outcome: 9-7: Explain cardiac tamponade

1 Fluid or blood continues to accumulate in the pericardial sac

2 The cause of the tamponade was persistent hypertension

3 Treatment by needle aspiration of the fluid in the sac is performed

4 A pericardial window is surgically created

Rationale 1: Unless immediate treatment is initiated, the tamponade will reoccur Rationale 2: Cardiac tamponade is not caused by hypertension

Rationale 3: This is a treatment to repair cardiac tamponade

Rationale 4: This is a treatment to repair cardiac tamponade

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