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Understanding the Essentials of Critical Care Nursing, 2nd Edition Test Bank – Perrin

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Understanding the Essentials of Critical Care Nursing, 2nd Edition Test Bank – Perrin
What: TEST BANK
Year Published: 2012
Authors: Perrin
Edition: 2nd

Product Description

Understanding the Essentials of Critical Care Nursing, 2nd Edition Test Bank – Perrin

 

Understanding the Essentials of Critical Care Nursing, 2nd Edition Test Bank – Perrin

 

 

 

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e
Chapter 9

Question 1

Type: MCSA

A patient arrives in the emergency department with a flail chest after a motor vehicle accident (MVA) in which the patient’s chest hit the steering wheel. The nurse realizes this injury is due to:

  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 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

Correct Answer: 4

Rationale 1: This is an example of blunt trauma in which the skin is not broken, but underlying tissue is damaged.

Rationale 2: This is an example of blunt trauma in which the skin is not broken, but underlying tissue is damaged.

Rationale 3: 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.

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 3

Type: MCMA

When performing a quick assessment to identify life-threatening problems in a trauma patient, the nurse would include which assessments under the D–Disability section?

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
  2. Vital signs
  3. Ability to respond to verbal command
  4. Level of consciousness or unconsciousness
  5. Oxygen saturation levels

Correct Answer: 1,3,4

Rationale 1: This is assessed under the disability part of the primary assessment.

Rationale 2: Vital signs are classified under F–Full set of vital signs.

Rationale 3: This is assessed under the disability part of the primary assessment.

Rationale 4: This is assessed under the disability part of the primary assessment.

Rationale 5: Oxygen levels are covered under C–Circulation of the primary assessment steps.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

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

 

Question 4

Type: MCSA

What activities would the nurse implement under the A section of assessment priorities when admitting a trauma patient with a suspected spinal cord injury?

  1. Using a manual ventilation bag
  2. Applying heated blankets
  3. Using the jaw thrust maneuver
  4. Assessing for history of asthma

Correct Answer: 3

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.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

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?

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

Standard Text: Select all that apply.

  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 failure.

Rationale 3: This can obstruct the airflow into or out of the lungs and cause airway failure.

Rationale 4: This can obstruct the airflow into or out of the lungs and cause airway failure.

Rationale 5: This can obstruct the airflow into or out of the lungs and cause airway failure.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-4: 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.

Correct Answer: 1

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.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

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

 

Question 7

Type: MCSA

Which assessment finding indicates that a trauma patient is having problems with breathing rather than difficulty maintaining an airway?

  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

Correct Answer: 2

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.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

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

 

Question 8

Type: MCMA

Which will the nurse assess when evaluating breathing in a patient suspected of having a thoracic trauma?

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

Standard Text: Select all that apply.

  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

Correct Answer: 1,2,3,4

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.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

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)

Correct Answer: 1

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.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-5: Compare and contrast manifestations and management of various types of thoracic trauma.

 

Question 10

Type: MCMA

Which goals are appropriate for a patient with a traumatic injury and an ineffective breathing pattern?

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

Standard Text: Select all that apply.

  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.

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.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-5: Compare and contrast manifestations and management of various types of thoracic trauma.

 

Question 11

Type: MCMA

In the patient with thoracic trauma, what would the nurse identify as potential problems?

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

Standard Text: Select all that apply.

  1. Pleural effusion
  2. Subcutaneous emphysema
  3. Tracheal shift
  4. Vertebral column injury
  5. Bladder rupture

Correct Answer: 1,2,3,4

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.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-5: Compare and contrast manifestations and management of various types of thoracic trauma.

 

Question 12

Type: MCMA

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

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

Standard Text: Select all that apply.

  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.

Correct Answer: 1,2,4,5

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.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-5: Compare and contrast manifestations and management of various types of thoracic trauma.

 

Question 13

Type: MCSA

When discussing hemorrhagic shock with a nursing class, which statement by a student indicates to the nurse educator that additional teaching is required?

  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.

Correct Answer: 2

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:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 9-6: Recognize the manifestations of hemorrhagic shock and plan management strategies.

 

Question 14

Type: MCSA

When managing shock, which statement would be incorrect when comparing the level or classification of shock to the drug treatment?

  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

Correct Answer: 1

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.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-6: Recognize the manifestations of hemorrhagic shock and plan management strategies.

 

Question 15

Type: MCMA

During the assessment of a patient with a suspected cardiac tamponade, the nurse should monitor for the development of:

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

Standard Text: Select all that apply.

  1. Pulsus paradoxus
  2. Muffled heart sounds
  3. Hypotension
  4. Flat jugular veins

Correct Answer: 1,2,3

Rationale 1: This is a symptom of cardiac tamponade.

Rationale 2: This is a symptom of cardiac tamponade.

Rationale 3: 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 to move.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-7: Explain cardiac tamponade.

 

Question 16

Type: MCSA

The nurse identifies that a patient is at risk for the development of reoccurring cardiac tamponade when:

  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.

Correct Answer: 1

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.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-7: Explain cardiac tamponade.

 

Question 17

Type: MCSA

A nurse notes that a patient with a traumatic brain injury is having a rapid decline in level of consciousness. If the nurse suspects cerebral herniation the most appropriate intervention would be to:

  1. Briefly hyperventilate the patient.
  2. Take measures to increase intracranial pressures by Trendelenburg positioning.
  3. Prepare for emergency surgical repair.
  4. Contact the family to come say their last words with the patient.

Correct Answer: 1

Rationale 1: Hyperventilating the patient lowers the ICP by lowering the PaCO2 that is causing vasoconstriction of the cerebral blood vessels and reducing cerebral blood flow.

Rationale 2: This position places the patient at greater risk of permanent damage from decreased cerebral blood flow.

Rationale 3: Emergency surgery might be needed but hyperventilating the patient will temporarily allow more time for informed decision making.

Rationale 4: Although this may be a life and death event, the activity that might reduce this risk can be temporarily avoided by hyperventilation first.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-8: Identify the patient with a spinal cord injury and describe management of the injury.

 

Question 18

Type: MCSA

Which goal would receive the highest priority when caring for the patient with a cervical spine injury?

  1. Relieve muscle spasm pain
  2. Maintain cervical alignment
  3. Support respiratory effort and prevent atelectasis
  4. Promote hypothermia

Correct Answer: 3

Rationale 1: Pain relief is not of the highest priority at this time.

Rationale 2: Cervical alignment is not of the highest priority at this time.

Rationale 3: Due to the risk of airway obstruction and damage to nerves that stimulate respiratory function, ventilation may need to be controlled or assisted. Maintaining oxygenation is the priority at this time.

Rationale 4: Promoting hypothermia is not of the highest priority at this time.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-8: Identify the patient with a spinal cord injury and describe management of the injury.

 

Question 19

Type: MCSA

The mother of a patient just admitted with a spinal cord injury is asking if the patient will be given steroids. What would be an accurate way for the nurse to explain the role of steroids in treating spinal cord injuries?

  1. Steroids will make the patient feel better overall and retain muscle strength due to its “muscle-bulking” effects.
  2. Steroids have few side effects and remove all symptoms while healing the problem.
  3. Steroids can lead to “road-rage and anger outbursts” and therefore are avoided except under extreme emergencies.
  4. Steroids limit spinal cord edema and ischemia if initiated within 3 hours of the trauma and given for 48 hours.

Correct Answer: 4

Rationale 1: This is not the reason for using steroids in the patient with a spinal cord injury.

Rationale 2: These drugs do have some major side effects such as hyperglycemia, hypertension, redistribution of fat pads, and edema, as well as others that can be life threatening.

Rationale 3: This is not a concern for the patient with a spinal cord injury.

Rationale 4: This is due to the anti-inflammatory effect of steroid therapy and would be the best response for the nurse to make.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-8: Identify the patient with a spinal cord injury and describe management of the injury.

 

Question 20

Type: MCMA

The nurse is caring for a patient with a traumatic injury to the abdomen who is prescribed conservative, non-operative management. Which ongoing assessments should the nurse include in the plan of care?

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

Standard Text: Select all that apply.

  1. Hourly vital signs
  2. Assessment of the degree and type of guarding or rigidity
  3. Hourly CVP readings
  4. ECG changes for bradycardia and widening QRS
  5. Widening pulse pressure

Correct Answer: 1,2,3

Rationale 1: This would be done in the patient with a traumatic abdominal injury to assess for peritonitis.

Rationale 2: This would be done in the patient with a traumatic abdominal injury to assess for peritonitis.

Rationale 3: This would be done to assess fluid status and the onset of hypovolemic shock in the patient with a traumatic abdominal injury.

Rationale 4: The ECG will show tachycardia from hypovolemia. Widening QRS show slowed conduction in the ventricles and would not be a sign of abdominal distress.

Rationale 5: Widening pulse pressure is not seen in the patient with traumatic abdominal injury.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-9: Describe elements of an abdominal assessment of the patient with a traumatic injury. Identify when surgery may be required.

 

Question 21

Type: MCSA

Under what circumstance would the nurse expect to prepare a patient for surgery when abdominal trauma has occurred? A patient with:

  1. A suspected splenic injury and who has received 1 unit of blood
  2. A Grade III liver injury with stable vital signs
  3. A contusion to the kidney with a stable H & H
  4. A pelvic fracture with muscle rigidity of the abdominal wall

Correct Answer: 4

Rationale 1: If additional bleeding requires more than 2 units of blood or becomes unstable, the patient with splenic injury will require surgical repair to stop the bleeding.

Rationale 2: In a Grade III liver injury, conservative management outweighs the risks of surgery. If a Grade IV or V injury occurs in the liver, then surgical repair is called for immediately.

Rationale 3: With a contusion to the kidney bedrest and careful assessment of renal status is enough for the contusion to resolve with time.

Rationale 4: The patient with a pelvic fracture is exhibiting signs of bladder rupture by the muscle rigidity. Immediate surgery is required to assess and repair the damage to internal organs.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-9: Describe elements of an abdominal assessment of the patient with a traumatic injury. Identify when surgery may be required.

 

Question 22

Type: MCSA

Under the F section of the assessment process, in addition to full vital signs, the family is considered as a part of the treatment process. Which approach to the family would be most appropriate for the nurse to use?

  1. The family gets in the way of acute care management so the nurse should offer no support until the patient is stable.
  2. Ethically the family has a right to support the patient by being at the bedside during acute care management, including trauma resuscitation.
  3. Depending on the family’s awareness of health care management, they have the privilege to watch the care if they do not get in the way of the care.
  4. Because the care during trauma management can be too graphic for family to witness, the family should not be allowed at the bedside.

Correct Answer: 2

Rationale 1: This is a bias and it has been shown that having family at the bedside to support the patient will frequently give a better outcome.

Rationale 2: Legally and ethically the family has the right to be with the patient under all circumstances, including trauma resuscitation. This topic is greatly debated but the right is still present and often left to the physician to decide if the family should step out.

Rationale 3: With or without the medical/health care background, the right is still present and it is not a privilege to be awarded by staff.

Rationale 4: Even if the circumstance is graphic for the family, the right is present and benefits will be gained by the patient. The focus of care is not the family’s needs first but the patient’s.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-10: Analyze the benefits of family presence during trauma resuscitation and care.

 

Question 23

Type: MCMA

What can the nurse do to convey comfort to a trauma patient?

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

Standard Text: Select all that apply.

  1. Explain and talk to the patient, not ignore the patient.
  2. Give clear precise directions to follow.
  3. Directly look at the eyes of the patient when talking.
  4. Human contact such as a reassuring touch.
  5. Giving all details to get full cooperation.

Correct Answer: 1,2,3,4

Rationale 1: This will convey comfort to a trauma patient.

Rationale 2: This will convey comfort to a trauma patient.

Rationale 3: This will convey comfort to a trauma patient.

Rationale 4: This will convey comfort to a trauma patient.

Rationale 5: Giving extensive details will delay care and often confuses the patient in a traumatic situation and increases the patient’s anxiety rather than reducing stress. A patient under stress can best comprehend and follow brief directions given in a comforting manner to allow the staff to do their job without having to over explain or rationalize why they are doing what they are doing during the “golden” hour that may mean the difference between life and death.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Caring

Learning Outcome: 9-11: Discuss ways a nurse might provide comfort to the trauma patient.

 

Question 24

Type: MCMA

The nurse would include which activities when planning care to increase comfort for the intubated patient?

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

Standard Text: Select all that apply.

  1. Speak directly to the patient by looking into the patient’s eyes.
  2. Keep the patient sedated and let the patient sleep when giving care.
  3. Give additional pain medication whenever restlessness is noted.
  4. Establish a communication method that does not require talking.
  5. Keep the family at the bedside to interpret the patient’s needs.

Correct Answer: 1,4

Rationale 1: Developing eye contact will give comfort and reassurance when the patient is unable to speak while intubated.

Rationale 2: Sedation and not talking to the patient do not give support to the patient. Sedation may be needed but explaining the reason and timing for such should be for the improved ventilatory effectiveness and not the nurse’s convenience.

Rationale 3: Pain medication needs to be given based on the patient’s interpretation of its need. Restlessness is often a symptom of hypoxia and further assessment needs to be done before just medicating the patient.

Rationale 4: Developing a separate method of communication such as blinking one’s eyes or squeezing the nurse’s hand will give comfort and reassurance when the patient is unable to speak while intubated.

Rationale 5: It is not the family’s role to communicate or to meet the needs of the patient. It is a nursing obligation to identify and meet the needs of the patient.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-11: Discuss ways a nurse might provide comfort to the trauma patient.

 

Question 25

Type: MCMA

The nurse is planning interventions for a trauma patient to prevent the onset of the lethal triad. What will the nurse include in this patient’s plan of care?

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

Standard Text: Select all that apply.

  1. Monitor temperature.
  2. Measure intake and output.
  3. Evaluate laboratory data.
  4. Assess arterial blood gas values.
  5. Measure gastric pH.

Correct Answer: 1,2,3,4

Rationale 1: Monitoring body temperature is critical in the prevention of deaths from the lethal triad.

Rationale 2: Measuring intake and output is critical in the prevention of deaths from the lethal triad.

Rationale 3: Evaluating recent laboratory data is critical in the prevention of deaths from the lethal triad.

Rationale 4: Assessing arterial blood gas values is critical in the prevention of deaths from the lethal triad.

Rationale 5: Measuring gastric pH is not critical in the prevention of deaths from the lethal triad.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9-3: Explain the “lethal triad” of trauma mortality.

 

Question 26

Type: MCMA

The nurse is preparing to complete the secondary survey of a patient admitted with a traumatic chest injury. On what will the nurse focus when conducting this survey?

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

Standard Text: Select all that apply.

  1. Full set of vital signs
  2. Comfort measures
  3. Head-to-toe assessment
  4. Assessment of posterior surfaces
  5. Exposure

Correct Answer: 1,2,3,4

Rationale 1: This is a part of the secondary trauma survey.

Rationale 2: This is a part of the secondary trauma survey.

Rationale 3: This is a part of the secondary trauma survey.

Rationale 4: This is a part of the secondary trauma survey.

Rationale 5: This is a part of the primary trauma survey.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

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

 

Question 27

Type: MCMA

The nurse is concerned that a patient receiving emergency care for maxillofacial injuries from a motor vehicle crash sustained laryngeal trauma because of which assessment findings?

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

Standard Text: Select all that apply.

  1. Hoarse speech
  2. Pain when swallowing
  3. Coughing blood
  4. Epistaxis
  5. Periorbital edema

Correct Answer: 1,2,3

Rationale 1: The patient with laryngeal trauma will demonstrate hoarse speech.

Rationale 2: Painful swallowing is a manifestation of laryngeal trauma.

Rationale 3: Hemoptysis is a manifestation of laryngeal trauma.

Rationale 4: Epistaxis is not a manifestation of laryngeal trauma but would be present because of the maxillofacial trauma.

Rationale 5: Periorbital edema is not a manifestation of laryngeal trauma but would be present because of the maxillofacial trauma.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

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

 

Question 28

Type: MCMA

The nurse assesses a patient with a penetrating abdominal wound as a Class IV hemorrhage because of which findings?

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

Standard Text: Select all that apply.

  1. Heart rate 160
  2. Respiratory rate 28
  3. Mean arterial pressure 50
  4. Capillary refill 5 seconds
  5. Mild decrease in urine output

Correct Answer: 1,2,3,4

Rationale 1: Heart rate greater than 140 is an indication of Class IV hemorrhage.

Rationale 2: Tachypnea is an indication of Class IV hemorrhage.

Rationale 3: Mean arterial pressure less than 60 is an indication of Class IV hemorrhage.

Rationale 4: Delayed capillary refill is an indication of Class IV hemorrhage.

Rationale 5: Mild decrease in urine output would be seen in a Class II hemorrhage.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-6: Recognize the manifestations of hemorrhagic shock and plan management strategies.

 

Question 29

Type: MCMA

While caring for a patient with thoracic injuries from a motor vehicle crash, the nurse suspects the patient is developing cardiac tamponade because of which assessment findings?

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

Standard Text: Select all that apply.

  1. Dropping blood pressure
  2. Jugular vein distention
  3. Muffled heart sounds
  4. Drop in blood pressure on inspiration
  5. Increase in blood pressure on inspiration

Correct Answer: 1,2,3,4

Rationale 1: Hypotension is an assessment finding within Beck’s triad indicating cardiac tamponade.

Rationale 2: An increase in central venous pressure assessed as jugular vein distention is an assessment finding within Beck’s triad indicating cardiac tamponade.

Rationale 3: Heart sounds are muffled in cardiac tamponade because of the accumulation of fluid in the pericardial sac. This is an assessment finding within Beck’s triad indicating cardiac tamponade.

Rationale 4: In paradoxical pulse, blood pressure is at least 10 mm Hg higher on expiration than on inspiration. This is an assessment finding of cardiac tamponade.

Rationale 5: In cardiac tamponade, the blood pressure is higher on expiration than inspiration.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-7: Explain cardiac tamponade.

 

Question 30

Type: MCMA

A patient is admitted with injuries sustained from a skiing accident. While completing the primary survey, the nurse suspects the patient has an injury to the spleen because of which findings?

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

Standard Text: Select all that apply.

  1. Heart rate 120
  2. Referred pain to the left shoulder
  3. Upper left quadrant abdominal pain
  4. Hematuria
  5. Flank ecchymosis

Correct Answer: 1,2,3

Rationale 1: A rapid heart rate can indicate hemorrhage or hypovolemic shock which is an assessment finding consistent with an injury to the spleen.

Rationale 2: Kehr’s sign is referred pain to the left shoulder. This is an assessment finding consistent with an injury to the spleen.

Rationale 3: Upper left quadrant abdominal tenderness or pain is an assessment finding consistent with an injury to the spleen.

Rationale 4: Hematuria is not an assessment finding consistent with an injury to the spleen.

Rationale 5: Bruising or ecchymosis over the flank area is not an assessment finding consistent with an injury to the spleen.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9-9: Describe elements of an abdominal assessment of the patient with a traumatic injury. Identify when surgery may be required.

 

Question 31

Type: MCMA

A patient with massive injuries to the head and chest has died. The family is in the hallway waiting to see the patient. What can the nurse do to prepare the family to be with the patient at this time?

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

Standard Text: Select all that apply.

  1. Remove blood soaked bed sheets and gown.
  2. Have at least one of the patient’s hands readily available for the family to touch.
  3. Place the stretcher in the low position.
  4. Turn one dim light on in the room.
  5. Leave the family to visit with the patient.

Correct Answer: 1,2,3,4

Rationale 1: The nurse should remove body fluids from the environment.

Rationale 2: The nurse should make sure the patient’s hand is out and secured.

Rationale 3: The nurse should make sure the stretcher is in the low position so that chairs can be placed around it.

Rationale 4: Turning on one dim light in the room calms the room.

Rationale 5: The nurse should be present to answer questions and provide support.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Caring

Learning Outcome: 9-10: Analyze the benefits of family presence during trauma resuscitation and care.

 

Question 32

Type: MCMA

A patient with traumatic injuries to the abdomen expresses the fear of dying. What can the nurse do to provide comfort to the patient at this time?

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

Standard Text: Select all that apply.

  1. Face the patient when talking.
  2. State phrases that demonstrate care and comfort.
  3. Hold the patient’s hand.
  4. Provide pain medication.
  5. Leave the patient to rest.

Correct Answer: 1,2,3

Rationale 1: Using the en face position is comforting to a patient with traumatic injuries.

Rationale 2: Using comfort talk is helpful to the patient with traumatic injuries.

Rationale 3: Providing physical contact by holding the patient’s hand provides comfort to the patient with traumatic injuries.

Rationale 4: The use of pain medication is not identified as an intervention to provide comfort to the patient with traumatic injuries.

Rationale 5: Leaving the patient alone is not identified as an intervention of comfort to the patient with traumatic injuries.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Caring

Learning Outcome: 9-11: Discuss ways a nurse might provide comfort to the trauma patient.

 

Understanding the Essentials of Critical Care Nursing, 2nd Edition Test Bank – Perrin

 

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