Test bank for medical surgical nursing 6th edition by ignatavicius

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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.




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.

DIF: Cognitive Level: Comprehension
OBJ: Learning Outcome 1

REF: p. 127




TOP: Client Needs Category: Safe and Effective Care Environment (Management of
Care)
MSC: Integrated Process: Communication and Documentation

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.

DIF: Cognitive Level: Comprehension

REF: p. 127

OBJ: Learning Outcome 2
TOP: Client Needs Category: Safe and Effective Care Environment (Management of
Care)




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

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
TOP: Client Needs Category: Safe and Effective Care Environment (Management of
Care)
MSC: Integrated Process: Communication and Documentation

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.

DIF: Cognitive Level: Application

REF: N/A for Application and above

OBJ: Learning Outcome 3
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

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.

DIF: Cognitive Level: Application

REF: N/A for Application and above

OBJ: Learning Outcome 3
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




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

OBJ: Learning Outcome 4
TOP: Client Needs Category: Safe and Effective Care Environment (Management of
Care)
MSC: Integrated Process: Communication and Documentation

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
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

OBJ: Learning Outcome 4
TOP: Client Needs Category: Safe and Effective Care Environment (Management of
Care)

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




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.

DIF: Cognitive Level: Application

REF: N/A for Application and above

OBJ: Learning Outcome 5
TOP: Client Needs Category: Safe and Effective Care Environment (Management of
Care)
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




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.

DIF: Cognitive Level: Application

REF: N/A for Application and above

OBJ: Learning Outcome 5
TOP: Client Needs Category: Safe and Effective Care Environment (Management of
Care)
MSC: Integrated Process: Nursing Process (Assessment)

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




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.

DIF: Cognitive Level: Application

REF: N/A for Application and above

OBJ: Learning Outcome 7
TOP: Client Needs Category: Safe and Effective Care Environment (Management of
Care)
MSC: Integrated Process: Nursing Process (Assessment)

12. The emergency medical technicians (EMTs) arrive at the emergency room
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
TOP: Client Needs Category: Safe and Effective Care Environment (Management of

Care)
MSC: Integrated Process: Nursing Process (Assessment)

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




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

DIF: Cognitive Level: Application

REF: N/A for Application and above

OBJ: Learning Outcome 9
TOP: Client Needs Category: Safe and Effective Care Environment (Management of
Care)
MSC: Integrated Process: Nursing Process (Assessment)

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

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.

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)

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




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
OBJ: Learning Outcome 6

REF: N/A for Application and above




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

DIF: Cognitive Level: Application

REF: N/A for Application and above

OBJ: Learning Outcome 9
TOP: Client Needs Category: Safe and Effective Care Environment (Management of
Care)
MSC: Integrated Process: Nursing Process (Assessment)

MATCHING

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

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




1. Emergency medical technicians provide oxygen and vital sign monitoring

2. Paramedics arrive and start IV access

3. Nurse and other health care provider(s) perform assessment

4. Laboratory technician obtains blood specimens

5. Emergency room nurse gives a report on the client

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

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)

3. ANS: D

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)

4. ANS: F

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)

5. ANS: B

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)

6. ANS: A

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)