You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients:
- An ambulatory, dazed 25-year-old male with a bandaged head wound
- An irritable infant with a fever, petechiae, and nuchal rigidity
- A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
- A 50-year-old female with moderate abdominal pain
and occasional vomiting.
- A, B, D, C
- B, A, D, C
- C, D, B, A
- C, B, A, D
B. B, A, D, C
In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey?
- Complete set of vital signs
- Palpation and auscultation of the abdomen
- Brief neurologic assessment
- Initiation of pulse oximetry
C. Brief neurologic assessment
You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform.
- Perform the chin lift or jaw thrust maneuver.
- Establish unresponsiveness.
- Initiate cardiopulmonary resuscitation (CPR).
- Call for help and activate the code team.
- Instruct a nursing
assistant to get the crash cart.
- A, B, C, E, D
- B, D, A, C, E
- C, A, B, E, D
- D, C, B, E, A
- E, C, D, B, A
B. B, D, A, C, E
A client with trauma to the chest develops a tension pneumothorax. After a needle thorocostomy is performed the nurse would expect:
- an increase in blood pressure.
- a decrease in blood pressure.
- an increase in jugular venous distension.
- a decrease in level of consciousness.
A. an increase in blood pressure.
A pediatric client is admitted to the neuro ICU with a closed-head injury sustained after falling out of a tree house. The mechanisms of injury this young client most likely sustained would be:
A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessments should the nurse make?
- Observe the color of the fingers
- Palpate the radial pulse under the cast
- Check the cast for odor and drainage
- Evaluate the response to analgesics
D. Evaluate the response to analgesics
A client presents in the emergency department after falling from a roof. A fracture of the femoral neck is suspected. Which of these assessments best support this diagnosis?
- The client reports pain in the affected leg
- A large hematoma is visible in the affected extremity
- The affected extremity is shortened, adducted, and extremely rotated
- The affected extremity is edematous
C. The affected extremity is shortened, adducted, and extremely rotated
When admitting a client with a fractured extremity, the nurse would focus the assessment on which of the following first?
- The area proximal to the fracture
- The actual fracture site
- The area distal to the fracture
- The opposite extremity for baseline comparison
C. The area distal to the fracture
Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus?
- Acute respiratory distress syndrome
- Migraine like headaches
- Numbness in the right leg
- Muscle spasms in the right thigh
A. Acute respiratory distress syndrome
Following x-rays of an injured wrist, the patient is informed that it is badly sprained. In teaching the patient to care for the injury, the nurse tells the patient to
- apply a heating pad to reduce muscle spasms.
- wear an elastic compression bandage continuously.
- use pillows to keep the arm elevated above the heart.
- gently exercise the joint to prevent muscle shortening.
C. use pillows to keep the arm elevated above the heart.
A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the patient's symptoms are most likely related to fat embolism when assessment of the patient reveals
- a blood pressure of 100/65 mm Hg.
- anxiety, restlessness, and confusion.
- warm, reddened areas in the calf.
- pinpoint red areas on the upper chest.
D. pinpoint red areas on the upper chest.
Based on the nurse's understanding of the physiology of bone and cartilage, the injury that the nurse would expect to heal most rapidly is a:
- fracture of the midhumerus.
- torn knee cruciate ligament.
- fractured nose.
- severely sprained ankle.
A. fracture of the midhumerus.
When the health care provider tells a patient that the pain in the patient's knee is caused by bursitis, the patient asks the nurse to explain just what bursitis is. The nurse's best response would be to tell the patient bursitis is an inflammation of
- the fibrocartilage that acts as a shock absorber in the knee joint.
- a small, fluid-filled sac found at many joints.
- any connective tissue that is found supporting the joints of the body.
- the synovial membrane that lines the area between two bones of a joint.
B. a small, fluid-filled sac found at many joints.
A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?
- Vomiting continues
- Intracranial pressure (ICP) is increased
- The client needs mechanical ventilation
- Blood is anticipated in the cerebralspinal fluid (CSF)
B. Intracranial pressure (ICP) is increased
A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?
- To reduce intraocular pressure
- To prevent acute tubular necrosis
- To promote osmotic diuresis to decrease ICP
- To draw water into the vascular system to increase blood pressure
C. To promote osmotic diuresis to decrease ICP
A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?
- Urine output increases
- Pupils are 8 mm and nonreactive
- Systolic blood pressure remains at 150 mm Hg
- BUN and creatinine levels return to normal
A. Urine output increases
Which of the following signs and symptoms of increased ICP after head trauma would appear first?
- Large amounts of very dilute urine
- Restlessness and confusion
- Widened pulse pressure
C. Restlessness and confusion
Problems with memory and learning would relate to which of the following lobes?
While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional?
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?
- Sternal rub
- Pressure on the orbital rim
- Squeezing the sternocleidomastoid muscle
- Nail bed pressure
D. Nail bed pressure
A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has:
- A cerebral lesion
- A temporal lesion
- An intact brainstem
- Brain death
C. An intact brainstem
The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?
- Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.
- Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.
- Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure.
- Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.
B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.
Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation (DIC)?
- Hemorrhagic skin rash
- Dyspnea on exertion
A. Hemorrhagic skin rash
A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care?
- No precautions are required as long as antibiotics have been started
- Maintain enteric precautions
- Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics
- Maintain neutropenic precautions
C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:
- A positive Brudzinski's sign
- A negative Kernig's sign
- Absence of nuchal rigidity
- A Glascow Coma Scale score of 15
A. A positive Brudzinski's sign
A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is:
- 52 mm Hg
- 88 mm Hg
- 48 mm Hg
- 68 mm Hg
A. 52 mm Hg
For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:
- Prevent respiratory alkalosis.
- Lower arterial pH.
- Promote carbon dioxide elimination.
- Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg
C. Promote carbon dioxide elimination.
A client who was in a motor vehicle accident a few days ago is now complaining of progressive weakness in his arms and upper body while the functioning of his lower limbs is unchanged. Which of the following might this client be experiencing?
- Central cord syndrome
- Whiplash syndrome
- Anterior cord syndrome
- Brown-Sequard syndrome
A. Central cord syndrome
A client with a spinal cord injury is exhibiting poikilothermia. Which of the following would be appropriate to include in this client's plan of care?
- Provide good perineal care.
- Pass nasogastric tube to decompress stomach.
- Keep client warm with extra blankets.
- Stimulate the anal-rectal reflex.
C. Keep client warm with extra blankets.
During an assessment of a patient's motor status with the Glasgow Coma scale, the patient assumes a posture of abnormal flexion. The nurse would document this finding as:
A patient is admitted with a subacute subdural hematoma. The nurse realizes this patient will most likely be treated with:
- Emergency craniotomy.
- Elective draining of the hematoma.
- Burr holes to remove the hematoma.
- Removal of the affected cranial lobe.
B. Elective draining of the hematoma.
A patient with a traumatic brain injury is in need of fluid replacement therapy to maintain a systole blood pressure of at least 90 mm Hg. The nurse realizes that the best fluid replacement for this patient would be:
- Normal saline.
- D5 1/2 0.9% NS
- 0.45% NS
A. Normal saline.
The client with an old C6 spinal cord injury complains of suddenly being too warm, with nasal congestion and a very red face. What is your next assessment?
- blood pressure
- input and output for previous 8 hours
- bowel for impaction
B. blood pressure
The nurse is caring for a client with a closed head injury. Which of the following would contribute to intracrainal hypertension?
- elevating the head of the bed
- quiet darkened environnent
A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
- Evaluate urine specific gravity
- Anticipate treatment for renal failure
- Provide emollients to the skin to prevent breakdown
- Slow down the IV fluids and notify the physician
A. Evaluate urine specific gravity
When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result?
- Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).
- Emergent; the client is poorly oxygenated.
- Significant; the client has alveolar hypoventilation.
A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).
A client with a C4 spinal injury would most likely have which of the following symptoms?
A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
- Place the client flat in bed
- Assess patency of the indwelling urinary catheter
- Give one SL nitroglycerin tablet
- Raise the head of the bed immediately to 90 degrees
D. Raise the head of the bed immediately to 90 degrees
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
- Laceration of the middle meningeal artery
- Rupture of the carotid artery
- Thromboembolism from a carotid artery
- Venous bleeding from the arachnoid space
A. Laceration of the middle meningeal artery
When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval?
- An interval when the client's speech is garbled
- An interval when the client is alert but can't recall recent events
- An interval when the client is oriented but then becomes somnolent
- An interval when the client has a "warning" symptom, such as an odor or visual disturbance.
C. An interval when the client is oriented but then becomes somnolent
Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia?
- Absence of pain sensation in chest
- Spontaneous respirations
- Urinary continence