ch. 11 med surg

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LeMone/Burke/Bauldoff, Medical-Surgical Nursing 5th Edition Test BankChapter 11

Question 1Type: MCSAA patient is brought to the emergency department with injuries sustained from a motor vehicle accident. The nurse realizes that this patients injuries have been caused by which of the following?

1. trauma2. not wearing a seat restraint3. a drunk driver4. not paying attention while drivingCorrect Answer: 1Rationale 1: Trauma is defined as injury to human tissues and organs resulting from the transfer of energy from the environment. Trauma encompasses a variety of injuries including those from motor vehicle crashes.Rationale 2: There is not enough information to determine if the patient was not wearing a seat restraint, if the accident was caused by a drunk driver, or if the patient was not paying attention while driving.Rationale 3: There is not enough information to determine if the patient was not wearing a seat restraint, if the accident was caused by a drunk driver, or if the patient was not paying attention while driving.Rationale 4: There is not enough information to determine if the patient was not wearing a seat restraint, if the accident was caused by a drunk driver, or if the patient was not paying attention while driving.Global Rationale: Trauma is defined as injury to human tissues and organs resulting from the transfer of energy from the environment. Trauma encompasses a variety of injuries including those from motor vehicle crashes. There is not enough information to determine if the patient was not wearing a seat restraint, if the accident was caused by a drunk driver, or if the patient was not paying attention while driving.Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 1. Define the word trauma.

Question 2Type: MCSAThe spouse of a patient admitted with a gunshot wound asks the nurse when her husband will be discharged so that they can resume their life together. With which of the following should the nurse respond to this spouse?

1. Right now there is no way of knowing how soon your husband can return to his previous life.2. I would say in a few weeks.3. Probably never.4. As soon as the wound heals your husband can return to work.Correct Answer: 1Rationale 1: Nurses provide a vital link in both the physical and psychosocial care for the injured patient and family. In caring for the patient who has experienced trauma, nurses must consider not only the initial physical injury, but also its long-term consequences, including rehabilitation. Trauma may alter the patients previous way of life, potentially effecting independence, mobility, cognitive thinking, and appearance. The nurse should respond that there is no way of knowing how soon the patient can return to his previous life.Rationale 2: The nurse should not put a time limit of a few weeks on the patients recovery from trauma.Rationale 3: The nurse also should not tell the spouse that the patient will probably never return to his previous life.Rationale 4: The nurse also has no way of knowing the extent of the damage caused by the gunshot wound and cannot predict when the patient can return to work.Global Rationale: Nurses provide a vital link in both the physical and psychosocial care for the injured patient and family. In caring for the patient who has experienced trauma, nurses must consider not only the initial physical injury, but also its long-term consequences, including rehabilitation. Trauma may alter the patients previous way of life, potentially effecting independence, mobility, cognitive thinking, and appearance. The nurse should respond that there is no way of knowing how soon the patient can return to his previous life. The nurse should not put a time limit of a few weeks on the patients recovery from trauma. The nurse also should not tell the spouse that the patient will probably never return to his previous life. The nurse also has no way of knowing the extent of the damage caused by the gunshot wound and cannot predict when the patient can return to work.Cognitive Level: ApplyingClient Need: Psychosocial Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 1. Define the word trauma.

Question 3Type: MCMAAn elderly patient is admitted after falling on the steps at home. Which of the following components does the nurse need to consider when planning care for the patient?

Standard Text: Select all that apply.1. host2. environment3. intention4. source5. transmissionCorrect Answer: 1,2,3Rationale 1: Host. The host is the person or group at risk of injury. Multiple factors influence the hosts potential for injury: age, sex, race, economic status, preexisting illnesses, and use of substances such as street drugs and alcohol. Since the patient is elderly, the nurse should consider the host when planning care.Rationale 2: Environment. The environment in which the trauma occurred needs to be taken into consideration. Since the patient fell on the steps at home, the nurse needs to keep this in mind when planning care.Rationale 3: Intention. The event was either intentional, planned, or unintentional. Since the patient fell on the steps at home, the event was most likely unintentional. Rationale 4: Source. Source is not a component of a traumatic event.Rationale 5: Transmission. Transmission is not a component of a traumatic event.Global Rationale: The host is the person or group at risk of injury. Multiple factors influence the hosts potential for injury: age, sex, race, economic status, preexisting illnesses, and use of substances such as street drugs and alcohol. Since the patient is elderly, the nurse should consider the host when planning care. The environment in which the trauma occurred needs to be taken into consideration. Since the patient fell on the steps at home, the nurse needs to keep this in mind when planning care. The event was either intentional, planned, or unintentional. Since the patient fell on the steps at home, the event was most likely unintentional. Source is not a component of a traumatic event. Transmission is not a component of a traumatic event.Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 2. Define the components and types of trauma.

Question 4Type: MCSAA patient comes into the emergency department with leg pain after falling on ice. The nurse realizes that this patients injuries would most likely be classified as being which of the following?

1. Class 3 minor2. Class 1 minor3. Class 1 penetrating4. Class 3 penetratingCorrect Answer: 1Rationale 1: Trauma patients are classified as Class 1, 2, or 3 based on factors including mechanism of injury, vehicle speed, height of falls, and location of penetrating injuries. Class 3 trauma is the least severe. An example would be a same level fall without loss of consciousness or significant injury. The patient who slipped and fell on ice is an example of a Class 3 trauma.Rationale 2: Class 1 trauma involves life-threatening injuries likely to require medical specialists or immediate surgical intervention. The patient did not sustain a Class 1 injury. Minor trauma causes injury to a single part or system of the body and is usually treated in a physicians office or in the hospital emergency department. A single bone fracture, small second-degree burns, or a laceration requiring sutures are examples of minor trauma. Since the patient is experiencing leg pain after the fall, the injury would be considered minor.Rationale 3: Penetrating trauma occurs when a foreign object enters the body causing damage to body structures. The patient fell and did not sustain a penetrating injury.Rationale 4: Penetrating trauma occurs when a foreign object enters the body causing damage to body structures. The patient fell and did not sustain a penetrating injury.Global Rationale: Trauma patients are classified as Class 1, 2, or 3 based on factors including mechanism of injury, vehicle speed, height of falls, and location of penetrating injuries. Class 3 trauma is the least severe. An example would be a same level fall without loss of consciousness or significant injury. The patient who slipped and fell on ice is an example of a Class 3 trauma. Class 1 trauma involves life-threatening injuries likely to require medical specialists or immediate surgical intervention. The patient did not sustain a Class 1 injury. Minor trauma causes injury to a single part or system of the body and is usually treated in a physicians office or in the hospital emergency department. A single bone fracture, small second-degree burns, or a laceration requiring sutures are examples of minor trauma. Since the patient is experiencing leg pain after the fall, the injury would be considered minor. Penetrating trauma occurs when a foreign object enters the body causing damage to body structures. The patient fell and did not sustain a penetrating injury.Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 2. Define the components and types of trauma.

Question 5Type: MCSAA patient is brought to the emergency department with injuries sustained from a wall that collapsed in the home. The nurse realizes that this patients injuries are most likely caused by which of the following?

1. crushing2. shearing3. deceleration4. blastCorrect Answer: 1Rationale 1: Blunt trauma occurs when there is communication between tissues and outside environment. A crushing injury occurs from a high force that leads to tissue destruction. The wall collapse on the patient most likely has injuries caused by crushing.Rationale 2: Shearing occurs when structures slip across each other.Rationale 3: Deceleration is the decrease of speed of a moving object.Rationale 4: Blast injuries result from the temperature and velocity of air movement and the force of projectiles from the explosion.Global Rationale: Blunt trauma occurs when there is communication between tissues and outside environment. A crushing injury occurs from a high force that leads to tissue destruction. The wall collapse on the patient most likely has injuries caused by crushing. Shearing occurs when structures slip across each other. Deceleration is the decrease of speed of a moving object. Blast injuries result from the temperature and velocity of air movement and the force of projectiles from the explosion.Cognitive Level: AnalyzingClient Need: Physiological Integrity


Question 6Type: MCSAA patient was admitted with a head injury caused by rapid acceleration and deceleration. The nurse realizes that the patients injuries could also be classified as being which of the following?

1. blunt2. shearing3. blast4. minorCorrect Answer: 1Rationale 1: Blunt trauma occurs when there is no communication between the damaged tissues and the outside environment. It is caused by various forces including deceleration, acceleration, shearing, compression, and crushing. Since the head injury was caused by acceleration and deceleration, this injury could be classified as being from blunt trauma.Rationale 2: Shearing is a type of blunt trauma.Rationale 3: Blast injuries result from the temperature and velocity of air movement and the force of projectiles from the explosion.Rationale 4: Minor trauma causes injury to a single part or system of the body and is usually treated in a physicians office or in the hospital emergency department.Global Rationale: Blunt trauma occurs when there is no communication between the damaged tissues and the outside environment. It is caused by various forces including deceleration, acceleration, shearing, compression, and crushing. Since the head injury was caused by acceleration and deceleration, this injury could be classified as being from blunt trauma. Shearing is a type of blunt trauma. Blast injuries result from the temperature and velocity of air movement and the force of projectiles from the explosion. Minor trauma causes injury to a single part or system of the body and is usually treated in a physicians office or in the hospital emergency department.Cognitive Level: AnalyzingClient Need: Physiological Integrity


Question 7Type: MCSAA patient is admitted with a thermal injury. The mechanism of injury that this patient most likely experienced would be which of the following?

1. fire2. lightning3. ultraviolet radiation4. gunshotCorrect Answer: 1Rationale 1: The energy source for the patients injury is thermal. Mechanisms of injury for thermal injuries include fire, heating appliances, and freezing temperatures.Rationale 2: The energy source for lightning is electrical.Rationale 3: The energy source for ultraviolet radiation is physical.Rationale 4: The energy source for a gunshot is mechanical.Global Rationale: The energy source for the patients injury is thermal. Mechanisms of injury for thermal injuries include fire, heating appliances, and freezing temperatures. The energy source for lightning is electrical. The energy source for ultraviolet radiation is physical. The energy source for a gunshot is mechanical.Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 3. Describe the result of energy transfer to the human body.

Question 8Type: MCSAA pediatric patient is admitted after ingesting a household cleaning solution. The nurse realizes that the energy source for this patients injuries would be which of the following?

1. chemical2. physical3. thermal4. mechanicalCorrect Answer: 1Rationale 1: The mechanism of injury for drugs, poisons, and industrial chemicals is chemical.Rationale 2: The mechanism of injury for physical assault, drowning, or explosions would be physical.Rationale 3: The mechanism of injury for heating appliances, fire, or freezing temperatures would be thermal.Rationale 4: The mechanism of injury for motor vehicle accidents would be mechanical.Global Rationale: The mechanism of injury for drugs, poisons, and industrial chemicals is chemical. The mechanism of injury for physical assault, drowning, or explosions would be physical. The mechanism of injury for heating appliances, fire, or freezing temperatures would be thermal. The mechanism of injury for motor vehicle accidents would be mechanical.Cognitive Level: AnalyzingClient Need: Physiological Integrity


Question 9Type: MCSAA patient recovering from a motor vehicle accident asks the nurse why he has so many injuries since the other car barely hit him. With which of the following should the nurse respond to the patient?

1. The car that hit you transferred a large amount of energy to your body causing injuries.2. You have other health problems that make the injuries worse.3. The driver of the other car intended to hit you.4. Since you are older, your injuries will be worse.Correct Answer: 1Rationale 1: The nurse needs to respond with a statement that explains the transfer of energy to the patients body causing injuries.Rationale 2: The response that addresses the patients other health problems and age would not explain the transfer of energy but rather identifies characteristics of the host.Rationale 3: The response that the driver of the other car intended to injure the patient addresses the intention of the trauma and not the transfer of energy.Rationale 4: The response that addresses the patients other health problems and age would not explain the transfer of energy but rather identifies characteristics of the host.Global Rationale: The nurse needs to respond with a statement that explains the transfer of energy to the patients body causing injuries. The response that addresses the patients other health problems and age would not explain the transfer of energy but rather identifies characteristics of the host. The response that the driver of the other car intended to injure the patient addresses the intention of the trauma and not the transfer of energy.Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 3. Describe the result of energy transfer to the human body.

Question 10Type: MCSAA construction worker was admitted after falling from the roof of a building. The energy source for this patients injuries was most likely caused by which of the following?

1. gravity2. mechanical3. physical4. electricalCorrect Answer: 1Rationale 1: The energy source for a fall is gravity.Rationale 2: The energy source for motor vehicle accidents is mechanical.Rationale 3: The energy source for physical assaults, explosions, and drowning is physical.Rationale 4: The energy source for lightning is electrical.Global Rationale: The energy source for a fall is gravity. The energy source for motor vehicle accidents is mechanical. The energy source for physical assaults, explosions, and drowning is physical. The energy source for lightning is electrical.Cognitive Level: AnalyzingClient Need: Physiological Integrity


Question 11Type: MCSAA patient is admitted to the hospital with injuries from a motor vehicle collision. During the nurses initial assessment, the patient develops hypotension, and severe jugular distension with a tracheal deviation. Which of the following should the nurse suspect is occurring with this patient?

1. tension pneumothorax2. hemorrhage3. compensatory shock4. hypovolemic shockCorrect Answer: 1Rationale 1: A tension pneumothorax is life-threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung.Rationale 2: The patient would not have jugular vein distention with a hemorrhage, compensatory shock, or hypovolemic shock.Rationale 3: The patient would not have jugular vein distention with a hemorrhage, compensatory shock, or hypovolemic shock.Rationale 4: The patient would not have jugular vein distention with a hemorrhage, compensatory shock, or hypovolemic shock.Global Rationale: A tension pneumothorax is life-threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung. The patient would not have jugular vein distention with a hemorrhage, compensatory shock, or hypovolemic shock.Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 4. Discuss causes, effects, and initial management of trauma.

Question 12Type: MCSAA patient is admitted with a diagnosis of blunt trauma to the abdomen after a motor vehicle collision. Which of the following should the nurse assess first when the patient arrives in the emergency department?

1. airway patency2. abdomen for any abnormalities3. cervical spine for tenderness4. signs of neurological deficitsCorrect Answer: 1Rationale 1: Assessment of the airway is the highest priority in the trauma patient. Assessment includes determining airway patency. If the patient is unresponsive, manual opening of the airway using a jaw thrust or chin lift maneuver is necessary. Once the airway is opened, the practitioner must identify any potential obstruction from the tongue, loose teeth, foreign bodies, bleeding, secretions, vomitus, or edema. If the patient is responsive and can vocalize, that is a good indication that the airway is clear.Rationale 2: All of the other responses are important, but certainly the nurse should address airway initially.Rationale 3: The nurse should assess the cervical spine area after initial ABC assessment.Rationale 4: The nurse is always concerned about the neurological assessment of a patient, but this patient has a blunt trauma injury from a motor vehicle; therefore, this would not be the initial assessment for the patient.Global Rationale: Assessment of the airway is the highest priority in the trauma patient. Assessment includes determining airway patency. If the patient is unresponsive, manual opening of the airway using a jaw thrust or chin lift maneuver is necessary. Once the airway is opened, the practitioner must identify any potential obstruction from the tongue, loose teeth, foreign bodies, bleeding, secretions, vomitus, or edema. If the patient is responsive and can vocalize, that is a good indication that the airway is clear. All of the other responses are important, but certainly the nurse should address the airway initially. The nurse should assess the cervical spine area after initial ABC assessment. The nurse is always concerned about the neurological assessment of a patient, but this patient has a blunt trauma injury from a motor vehicle; therefore, this would not be the initial assessment for the patient.Cognitive Level: ApplyingClient Need: Physiological Integrity


Question 13Type: MCSAA patient is brought to the emergency department with a penetrating wound to the neck. The patient is dyspneic and cyanotic, and has evidence of subcutaneous emphysema. What does the nurse expect the physician to do initially?

1. Intubate the patient because of the severe wound.2. Notify the next of kin regarding the patients condition.3. Order x-rays of the lumbar area to assess for fractures.4. Administer a beta blocker to alleviate the sympathetic response.Correct Answer: 1Rationale 1: Penetrating trauma to the neck is associated with a high degree of morbidity and mortality. Airway involvement includes dyspnea, cyanosis, subcutaneous emphysema, hoarseness, or air bubbling from the wound. The key is early identification of the need for intubation before the patient has no airway at all.Rationale 2: The physician will most likely do or prescribe the other options however the most important is to maintain the airway.Rationale 3: The physician will most likely do or prescribe the other options however the most important is to maintain the airway.Rationale 4: The physician will most likely do or prescribe the other options however the most important is to maintain the airway.Global Rationale: Penetrating trauma to the neck is associated with a high degree of morbidity and mortality. Airway involvement includes dyspnea, cyanosis, subcutaneous emphysema, hoarseness, or air bubbling from the wound. The key is early identification of the need for intubation before the patient has no airway at all. The physician will most likely do or prescribe the other options however the most important is to maintain the airway.Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 4. Discuss causes, effects, and initial management of trauma.

Question 14Type: MCSAThe nurse suspects that a patient who was in a motor vehicle accident does not have a cervical spine injury when which of the following is assessed?

1. alert without midline cervical tenderness2. no motor response of lower extremities3. lack of deep tendon reflexes4. lethargic and confusedCorrect Answer: 1Rationale 1: There is a decreased probability of a cervical spine injury if the following criteria are met: absence of midline cervical spine tenderness; normal alertness; absence of intoxication; absence of a painful distracting injury; and no focal neurological defects.Rationale 2: A lack of motor response, lack of deep tendon reflexes, lethargy, and confusion would be indications of a cervical spine injury.Rationale 3: A lack of motor response, lack of deep tendon reflexes, lethargy, and confusion would be indications of a cervical spine injury.Rationale 4: A lack of motor response, lack of deep tendon reflexes, lethargy, and confusion would be indications of a cervical spine injury.Global Rationale: There is a decreased probability of a cervical spine injury if the following criteria are met: absence of midline cervical spine tenderness; normal alertness; absence of intoxication; absence of a painful distracting injury; and no focal neurological defects. A lack of motor response, lack of deep tendon reflexes, lethargy, and confusion would be indications of a cervical spine injury.Cognitive Level: AnalyzingClient Need: Physiological Integrity


Question 15Type: MCSAA patient is brought to the emergency department with physical injuries sustained from a gang fight. The patients blood pressure is 80/50 mmHg with a pulse of 120 and thready. The nurse realizes that the diagnostic test that would provide the fastest information to help this patient would be which of the following?

1. sonogram2. complete blood count3. urinalysis4. serum electrolyte levelsCorrect Answer: 1Rationale 1: The focused assessment by sonography in trauma or FAST identifies blood in body cavities where it is not supposed to be. The primary focus is on the peritoneum. Since the patient was in a fight and has a low blood pressure and thready pulse, this diagnostic test would provide the fastest information to help the patient.Rationale 2: A complete blood count, urinalysis, and serum electrolyte levels would not provide the fastest information for this patient.Rationale 3: A complete blood count, urinalysis, and serum electrolyte levels would not provide the fastest information for this patient.Rationale 4: A complete blood count, urinalysis, and serum electrolyte levels would not provide the fastest information for this patient.Global Rationale: The focused assessment by sonography in trauma or FAST identifies blood in body cavities where it is not supposed to be. The primary focus is on the peritoneum. Since the patient was in a fight and has a low blood pressure and thready pulse, this diagnostic test would provide the fastest information to help the patient. A complete blood count, urinalysis, and serum electrolyte levels would not provide the fastest information for this patient.Cognitive Level: AnalyzingClient Need: Physiological Integrity


Question 16Type: MCSAA patient is admitted with possible head and spinal cord injuries sustained after falling from a ladder. The diagnostic test that will identify the type and extent of injuries for this patient would be which of the following?

1. magnetic resonance imaging2. cervical spine x-rays3. spinal cord x-rays4. cerebral angiogramCorrect Answer: 1Rationale 1: Magnetic resonance imaging scans discover injuries to the brain and spinal cord. This is the diagnostic test that should be done for this patient.Rationale 2: Cervical spine and spinal cord x-rays can detect fractures of the vertebra but will not detect injuries to the brain.Rationale 3: Cervical spine and spinal cord x-rays can detect fractures of the vertebra but will not detect injuries to the brain.Rationale 4: A cerebral angiogram can detect injuries to the brain but not of the spinal cord.Global Rationale: Magnetic resonance imaging scans discover injuries to the brain and spinal cord. This is the diagnostic test that should be done for this patient. Cervical spine and spinal cord x-rays can detect fractures of the vertebra but will not detect injuries to the brain. A cerebral angiogram can detect injuries to the brain but not of the spinal cord.Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 5. Discuss diagnostic tests used in assessing patients experiencing trauma and shock.

Question 17Type: MCMAA victim of a multi-vehicle automobile accident is brought into the emergency department. The patient has slurred speech and is lethargic. The nurse realizes that which of the following diagnostic tests would be indicated for this patient?

Standard Text: Select all that apply.1. blood alcohol level2. erine drug screen3. skull x-rays4. chest x-ray5. urinalysisCorrect Answer: 1,2Rationale 1: Blood alcohol level. Since alcohol alters a persons level of consciousness, the patient with slurred speech and lethargy would most likely have a blood alcohol level done.Rationale 2: Urine drug screen. Similar to alcohol, some drugs can cause lethargy and slurred speech. The patient would most like have a urine drug screen done.Rationale 3: Skull x-rays. This diagnostic test may or may not be indicated for the patient.Rationale 4: Chest x-ray. This diagnostic test will most likely be done however not because of slurred speech or lethargy. Rationale 5: Urinalysis. This diagnostic test will most likely be done however not because of slurred speech or lethargy.Global Rationale: Blood alcohol level. Since alcohol alters a persons level of consciousness, the patient with slurred speech and lethargy would most likely have a blood alcohol level done. Similar to alcohol, some drugs can cause lethargy and slurred speech. The patient would most like have a urine drug screen done. Skull x-rays may or may not be indicated for the patient. Chest x-ray will most likely be done however not because of slurred speech or lethargy. Urinalysis will most likely be done however not because of slurred speech or lethargy.Cognitive Level: AnalyzingClient Need: Physiological Integrity


Question 18Type: MCSAThe nurse determines that a patient is having ongoing progression of a shock state when which of the following is assessed?

1. decrease in serum glucose level2. drop in blood urea nitrogen level3. increased eosinophil level4. low serum cardiac enzyme levelCorrect Answer: 1Rationale 1: Serum electrolyte levels will be assessed to monitor the severity and progression of shock. As shock progresses, serum glucose levels will decrease.Rationale 2: A drop in blood urea nitrogen level means the kidneys are receiving adequate blood flow.Rationale 3: An increase in eosinophils indicates an allergic response.Rationale 4: Low serum cardiac enzymes indicate no myocardial damage.Global Rationale: Serum electrolyte levels will be assessed to monitor the severity and progression of shock. As shock progresses, serum glucose levels will decrease. A drop in blood urea nitrogen level means the kidneys are receiving adequate blood flow. An increase in eosinophils indicates an allergic response. Low serum cardiac enzymes indicate no myocardial damage.Cognitive Level: AnalyzingClient Need: Physiological Integrity


Question 19Type: MCSAA patient with multiple traumatic injuries has experienced severe blood loss and is prescribed to receive blood immediately. The nurse realizes that since there is not sufficient time for type and crossmatch, the patient will most likely receive which type of blood?

1. O2. A3. B4. ABCorrect Answer: 1Rationale 1: Type O blood is the universal donor. ABO antibodies develop in the serum of people whose RBCs lack the corresponding antigen; these antibodies are called anti-A and anti-B.Rationale 2: The person with blood type B has A antibodies, the person with type A has B antibodies, the person with type O has both types of antibodies, and the person with AB has no antibodies; therefore, this patient is known as the universal recipient.Rationale 3: The person with blood type B has A antibodies, the person with type A has B antibodies, the person with type O has both types of antibodies, and the person with AB has no antibodies; therefore, this patient is known as the universal recipient.Rationale 4: The person with blood type B has A antibodies, the person with type A has B antibodies, the person with type O has both types of antibodies, and the person with AB has no antibodies; therefore, this patient is known as the universal recipient.Global Rationale: Type O blood is the universal donor. ABO antibodies develop in the serum of people whose RBCs lack the corresponding antigen; these antibodies are called anti-A and anti-B. The person with blood type B has A antibodies, the person with type A has B antibodies, the person with type O has both types of antibodies, and the person with AB has no antibodies; therefore, this patient is known as the universal recipient.Cognitive Level: AnalyzingClient Need: Safe Effective Care Environment

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids.

Question 20Type: MCSAA patient with multiple gun shot wounds to the abdomen has received eight units of blood. The blood bank notifies the nurse that they have run out of blood for the patient. The nurse understands that the patient can receive any type of blood if the patient has which blood type?

1. AB2. A3. B4. OCorrect Answer: 1Rationale 1: The person with blood type A has B antibodies, someone with type B has A antibodies, someone with type AB has no antibodies, and a person who has type O blood has both antibodies. Therefore, the person with type AB blood can receive any type of blood in an emergency situation and is referred to as the universal recipient.Rationale 2: The person with blood type A has B antibodies, someone with type B has A antibodies, someone with type AB has no antibodies, and a person who has type O blood has both antibodies.Rationale 3: The person with blood type A has B antibodies, someone with type B has A antibodies, someone with type AB has no antibodies, and a person who has type O blood has both antibodies.Rationale 4: A person with the O blood type is considered a universal donor in an emergency situation.Global Rationale: The person with blood type A has B antibodies, someone with type B has A antibodies, someone with type AB has no antibodies, and a person who has type O blood has both antibodies. Therefore, the person with type AB blood can receive any type of blood in an emergency situation and is referred to as the universal recipient. A person with the O blood type is considered a universal donor in an emergency situation.Cognitive Level: AnalyzingClient Need: Safe Effective Care Environment

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids.

Question 21Type: MCSAA patient, admitted with multiple injuries, is prescribed to receive an intravenous colloid solution. Which one of the following solutions would be appropriate for the nurse to infuse?

1. 25% albumin2. 0.9% normal saline3. Dextrose 5% and 0.45 % normal saline4. Dextrose 5% and waterCorrect Answer: 1Rationale 1: Colloid solutions contain substances that should not diffuse through capillary walls. Colloids tend to remain in the vascular system and increase the osmotic pressure of the serum, causing fluid to move into the vascular compartment from the interstitial space. As a result, plasma volume expands. Colloid solutions used to treat shock include 5% albumin, 25% albumin, hetastarch, plasma protein fraction, and dextran.Rationale 2: Crystalloid solutions contain dextrose or electrolytes such as normal saline dissolved in water; they are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and the interstitial space.Rationale 3: Crystalloid solutions contain dextrose or electrolytes such as normal saline dissolved in water; they are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and the interstitial space.Rationale 4: Crystalloid solutions contain dextrose or electrolytes such as normal saline dissolved in water; they are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and the interstitial space.Global Rationale: Colloid solutions contain substances that should not diffuse through capillary walls. Colloids tend to remain in the vascular system and increase the osmotic pressure of the serum, causing fluid to move into the vascular compartment from the interstitial space. As a result, plasma volume expands. Colloid solutions used to treat shock include 5% albumin, 25% albumin, hetastarch, plasma protein fraction, and dextran. Crystalloid solutions contain dextrose or electrolytes such as normal saline dissolved in water; they are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and the interstitial space.Cognitive Level: ApplyingClient Need: Physiological Integrity


Question 22Type: MCSAA patient diagnosed with hypovolemic shock is prescribed intravenous fluids while awaiting blood transfusions. The nurse realizes that the solution of choice for this patient would be which of the following?

1. Ringers lactate2. Dextrose 5% and water3. Dextrose 5% and 0.45% normal saline4. Dextrose 5% and 0.9% normal salineCorrect Answer: 1Rationale 1: Ringers lactate and 0.9% saline are the fluids of choice in treating hypovolemic shock, especially in the emergency phase of care while blood is being typed and crossmatched. Large amounts of these solutions may be infused rapidly, increasing blood volume and tissue perfusion.Rationale 2: Hypotonic crystalloid solutions, such as Dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. But since approximately 25% of the fluid stays within the intravascular space, there is an increased risk of peripheral edema.Rationale 3: Hypotonic crystalloid solutions, such as Dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. But since approximately 25% of the fluid stays within the intravascular space, there is an increased risk of peripheral edema.Rationale 4: Hypotonic crystalloid solutions, such as Dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. But since approximately 25% of the fluid stays within the intravascular space, there is an increased risk of peripheral edema.Global Rationale: Ringers lactate and 0.9% saline are the fluids of choice in treating hypovolemic shock, especially in the emergency phase of care while blood is being typed and crossmatched. Large amounts of these solutions may be infused rapidly, increasing blood volume and tissue perfusion. Hypotonic crystalloid solutions, such as Dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. But since approximately 25% of the fluid stays within the intravascular space, there is an increased risk of peripheral edema.Cognitive Level: ApplyingClient Need: Physiological Integrity


Question 23Type: MCSAA patient diagnosed with shock is prescribed dobutamine (Dobutrex). Which of the following would the nurse assess as an effect of this medication?

1. increased heart rate2. reduced heart rate3. decreased respiratory rate4. decreased blood pressureCorrect Answer: 1Rationale 1: Dobutamine (Dobutrex) is a medication that mimics the fight-or-flight response of the sympathetic nervous system. The physiologic effect is improved perfusion and oxygenation of the heart, with increased stroke volume and heart rate, and increased cardiac output. Increased cardiac output in turn increases tissue perfusion and oxygenation.Rationale 2: This medication will not decrease the heart rate, decrease the respiratory rate, nor decrease the blood pressure.Rationale 3: This medication will not decrease the heart rate, decrease the respiratory rate, nor decrease the blood pressure.Rationale 4: This medication will not decrease the heart rate, decrease the respiratory rate, nor decrease the blood pressure.Global Rationale: Dobutamine (Dobutrex) is a medication that mimics the fight-or-flight response of the sympathetic nervous system. The physiologic effect is improved perfusion and oxygenation of the heart, with increased stroke volume and heart rate, and increased cardiac output. Increased cardiac output in turn increases tissue perfusion and oxygenation. This medication will not decrease the heart rate, decrease the respiratory rate, nor decrease the blood pressure.Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: EvaluationLearning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids.

Question 24Type: MCSAThe nurse is preparing to administer intravenous nitroglycerin to a patient diagnosed with cardiogenic shock. Which of the following should the nurse do when providing this medication?

1. Use an infusion pump.2. Administer with PVC tubing.3. Use within 8 hours of reconstitution.4. Patient permitted out of bed with assist only.Correct Answer: 1Rationale 1: Intravenous nitroglycerin must be mixed in glass bottles and infused through special, non-PVC tubing, because up to 40% to 80% of nitroglycerin can be absorbed by PVC bags or tubing.Rationale 2: Intravenous nitroglycerin must be mixed in glass bottles and infused through special, non-PVC tubing, because up to 40% to 80% of nitroglycerin can be absorbed by PVC bags or tubing.Rationale 3: This medication must be infused with an infusion pump, and used within four hours of reconstitution.Rationale 4: The patient receiving intravenous nitroglycerin should be on bedrest and not assisted out of bed.Global Rationale: Intravenous nitroglycerin must be mixed in glass bottles and infused through special, non-PVC tubing, because up to 40% to 80% of nitroglycerin can be absorbed by PVC bags or tubing. This medication must be infused with an infusion pump, and used within four hours of reconstitution. The patient receiving intravenous nitroglycerin should be on bed rest and not assisted out of bed.Cognitive Level: ApplyingClient Need: Physiological Integrity


Question 25Type: MCMAWhich of the following assessment findings would be seen in a patient who experienced a traumatic brain injury and is being evaluated for brain death?

Standard Text: Select all that apply.1. absence of gag or corneal reflex2. absence of oculovestibular reflex3. apnea with PaCO2 of 66 mmHg4. toxic metabolic disorders5. response to deep stimuliCorrect Answer: 1,2,3Rationale 1: Absence of gag or corneal reflex. This is a clinical sign that is consistent with brain death. Rationale 2: Absence of oculovestibular reflex. This is a clinical sign that is consistent with brain death.Rationale 3: Apnea with PaCO2 of 66 mm Hg. This is a clinical sign that is consistent with brain death.Rationale 4: Toxic metabolic disorders. This is not a sign that is consistent with brain death. Rationale 5: Response to deep stimuli. This is not a sign that is consistent with brain death.Global Rationale: Absence of gag or corneal reflex, absence of oculovestibular reflex, and apnea with PaCO2 of 66 mmHg are clinical signs consistent with brain death. Toxic metabolic disorders and response to deep stimuli are not a signs consistent with brain death.Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 7. Discuss organ donation and forensic implications of traumatic injury or death.

Question 26Type: MCSAThe spouse of a patient admitted with severe spinal cord injuries tells the nurse that she believes her husband is going to recover since he continues to make movements that occur without stimulation. Which of the following should the nurse explain to the spouse?

1. With spinal cord injuries, the patient can continue to make movements which are reflexes but do not reflect brain function.2. The patient will most likely recover in time.3. As long as he has oxygen to the brain, he will recover.4. His movements indicate that his brain is dead.Correct Answer: 1Rationale 1: One criteria of brain death is the lack of spontaneous movement, however, some spinal cord reflexes may be present. This is what the nurse should explain to the spouse regarding the patients movements.Rationale 2: The nurse should not tell the spouse that the patient will recover in time or will recover as long as he has oxygen to the brain.Rationale 3: The nurse should not tell the spouse that the patient will recover in time or will recover as long as he has oxygen to the brain.Rationale 4: The patient has severe spinal cord injuries. Telling the spouse that the patients movements indicate that the patients brain is dead is in inappropriate response.Global Rationale: One criterion of brain death is the lack of spontaneous movement, however, some spinal cord reflexes may be present. This is what the nurse should explain to the spouse regarding the patients movements. The nurse should not tell the spouse that the patient will recover in time or will recover as long as he has oxygen to the brain. The patient has severe spinal cord injuries. Telling the spouse that the patients movements indicate that the patients brain is dead is in inappropriate response.Cognitive Level: ApplyingClient Need: Psychosocial Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 7. Discuss organ donation and forensic implications of traumatic injury or death.

Question 27Type: MCSAA patient is brought to the emergency department with gunshot wounds to the abdomen and lower extremities. To protect the chain of evidence for these injuries, which of the following should the nurse do?

1. Remove the patients clothing and place in a breathable bag.2. Cover the patients hands with plastic bags.3. Cut off the patients clothing and bathe the skin and wounds as soon as possible.4. Place clothing and other patient items on a bedside table and have a nursing assistant remove when possible.Correct Answer: 1Rationale 1: Each item of clothing removed from the patient must be placed in a breathable container, such as a paper bag, and documented appropriately.Rationale 2: The patients hands should be covered with plastic bags only if the patient died.Rationale 3: The clothing should not be cut off in order to bathe the patients skin and wounds.Rationale 4: The patients clothing and personal items should not be left on a bedside table waiting for someone else to remove. This would not protect the chain of evidence.Global Rationale: Each item of clothing removed from the patient must be placed in a breathable container, such as a paper bag, and documented appropriately. The clothing should not be cut off in order to bathe the patients skin and wounds. The patients clothing and personal items should not be left on a bedside table waiting for someone else to remove. This would not protect the chain of evidence. The patients hands should be covered with plastic bags only if the patient died.Cognitive Level: ApplyingClient Need: Safe Effective Care Environment


Question 28Type: MCSAAn adult patient who has died from traumatic injuries is an organ donor. Which of the following should the nurse do when caring for this patient?

1. Maintain systolic blood pressure of 90 mmHg.2. Keep oxygen saturation level at 75%.3. Provide intravenous fluids for a urine output to be 25 mL per hour.4. Provide external cardiac compressions to achieve a heart rate of 60 beats per minute.Correct Answer: 1Rationale 1: When caring for an adult patient who is an organ donor, the nurse should: maintain systolic blood pressure of 90 mmHg to keep the patients organs perfused until removal ; maintain urine output at more than 30 mL per hour; and maintain oxygen saturation at 90% or greater.Rationale 2: When caring for an adult patient who is an organ donor, the nurse should maintain systolic blood pressure of 90 mmHg to keep the patients organs perfused until removal, maintain urine output at more than 30 mL per hour, and maintain oxygen saturation at 90% or greater.Rationale 3: When caring for an adult patient who is an organ donor, the nurse should maintain systolic blood pressure of 90 mmHg to keep the patients organs perfused until removal, maintain urine output at more than 30 mL per hour, and maintain oxygen saturation at 90% or greater.Rationale 4: External cardiac compressions should not be provided to achieve a heart rate of 60 beats per minute.Global Rationale: When caring for an adult patient who is an organ donor, the nurse should maintain systolic blood pressure of 90 mmHg to keep the patients organs perfused until removal, maintain urine output at more than 30 mL per hour, and maintain oxygen saturation at 90% or greater. External cardiac compressions should not be provided to achieve a heart rate of 60 beats per minute.Cognitive Level: ApplyingClient Need: Safe Effective Care Environment


Question 29Type: MCSAA patient with traumatic injuries has lost approximately 300 mL of blood. The nurse realizes that which of the following will most likely be assessed in this patient?

1. slight increase in heart rate2. nonpalpable peripheral pulses3. narrowing pulse pressure4. increase in blood glucose levelCorrect Answer: 1Rationale 1: With a slight decrease in circulating blood volume usually less than 500 mL the symptoms of shock are almost imperceptible. The pulse rate may be slightly elevated. If the injury is minor or of short duration, arterial pressure is usually maintained and no further symptoms occur.Rationale 2: Nonpalpable peripheral pulses, narrowing pulse pressure, and an increase in blood glucose level are all seen in progressive shock.Rationale 3: Nonpalpable peripheral pulses, narrowing pulse pressure, and an increase in blood glucose level are all seen in progressive shock.Rationale 4: Nonpalpable peripheral pulses, narrowing pulse pressure, and an increase in blood glucose level are all seen in progressive shock.Global Rationale: With a slight decrease in circulating blood volume usually less than 500 mL the symptoms of shock are almost imperceptible. The pulse rate may be slightly elevated. If the injury is minor or of short duration, arterial pressure is usually maintained and no further symptoms occur. Nonpalpable peripheral pulses, narrowing pulse pressure, and an increase in blood glucose level are all seen in progressive shock.Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 8. Discuss cellular homeostasis and basic hemodynamics.

Question 30Type: MCSAThe nurse wants to calculate a patients mean arterial pressure. Which of the following vital signs would the nurse use to make this calculation?

1. blood pressure2. temperature3. respirations4. heart rateCorrect Answer: 1Rationale 1: Rationale 2: Rationale 3: Rationale 4: Global Rationale: The mean arterial pressure can be calculated by multiplying the diastolic blood pressure by 2, adding the systolic pressure, and dividing this total by 3. The patients blood pressure is needed to make this calculation. The temperature, respirations, and heart rate are not used to calculate mean arterial pressure.Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 8. Discuss cellular homeostasis and basic hemodynamics.

Question 31Type: MCSAThe nurse is providing medications to increase a patients system vascular resistance. At which point will the nurse know that the patient has adequate tissue perfusion?

1. mean arterial pressure reaches 602. mean arterial pressure reaches 903. blood pressure reaches 120/80 mmHg4. urine output is 10 mL per hourCorrect Answer: 1Rationale 1: A mean arterial pressure of 60 mmHg is required to maintain adequate perfusion to the brain, heart, and kidneys.Rationale 2: A mean arterial pressure of 90 is considered within normal limits.Rationale 3: A blood pressure of 120/80 mmHg is considered normal.Rationale 4: A urine output of 10 mL per hour would not indicate adequate renal perfusion.Global Rationale: A mean arterial pressure of 60 mmHg is required to maintain adequate perfusion to the brain, heart, and kidneys. A mean arterial pressure of 90 is considered within normal limits. A blood pressure of 120/80 mmHg is considered normal. A urine output of 10 mL per hour would not indicate adequate renal perfusion.Cognitive Level: AnalyzingClient Need: Physiological Integrity


Question 32Type: MCSAA patient has an estimated blood loss of two liters and has a mean arterial pressure ranging between 30 and 40 mmHg. If this patients hemodynamic status is not corrected, the nurse realizes that which of the following can occur?

1. failure of sodium-potassium pump2. cells will shrink3. full and bounding peripheral pulses4. metabolic alkalosisCorrect Answer: 1Rationale 1: With a blood loss of two liters and a mean arterial pressure below 60 mmHg, the body cells will switch from aerobic to anaerobic metabolism. The lactic acid formed as a by-product of anaerobic metabolism contributes to an acidotic state at the cellular level. Adenosine triphosphate, the source of cellular energy, is produced inefficiently. Lacking energy, the sodium-potassium pump fails. Potassium moves out of the cell, while sodium and water move inward.Rationale 2: As this process continues, the cells swell and not shrink.Rationale 3: Peripheral pulses may not be palpable.Rationale 4: The body develops acidosis and not alkalosis.Global Rationale: With a blood loss of two liters and a mean arterial pressure below 60 mmHg, the body cells will switch from aerobic to anaerobic metabolism. The lactic acid formed as a by-product of anaerobic metabolism contributes to an acidotic state at the cellular level. Adenosine triphosphate, the source of cellular energy, is produced inefficiently. Lacking energy, the sodium-potassium pump fails. Potassium moves out of the cell, while sodium and water move inward. As this process continues, the cells swell and not shrink. Peripheral pulses may not be palpable. The body develops acidosis and not alkalosis.Cognitive Level: AnalyzingClient Need: Physiological Integrity


Question 33Type: MCSAThe nurse, caring for a patient who sustained a traumatic injury several days ago, notes that the patient is hypotensive, oliguric, and has cool, pale skin and acidosis. The nurse understands that these are manifestations of which of the following?

1. hypovolemic shock2. cardiogenic shock3. septic shock4. anaphylactic shockCorrect Answer: 1Rationale 1: Hypovolemic shock is caused by a decrease in intravascular volume. In hypovolemic shock, the venous blood returning to the heart decreases, and ventricular fills drops. As a result, stroke volume, cardiac output, and blood pressure decrease. Hypovolemic shock affects all body systems.Rationale 2: Cardiogenic shock occurs when the hearts pumping ability is compromised to the point that it cannot maintain cardiac output and adequate tissue perfusion.Rationale 3: Patients at risk for developing infections leading to septic shock include those who are hospitalized, have debilitating chronic illnesses, or have poor nutritional status. Septic shock does not usually present with a patient who presents with a traumatic injury.Rationale 4: Anaphylactic shock is the result of a widespread hypersensitivity reaction from medications, blood administration, latex, foods, snake venom, and insect stings.Global Rationale: Hypovolemic shock is caused by a decrease in intravascular volume. In hypovolemic shock, the venous blood returning to the heart decreases, and ventricular fills drops. As a result, stroke volume, cardiac output, and blood pressure decrease. Hypovolemic shock affects all body systems. Cardiogenic shock occurs when the hearts pumping ability is compromised to the point that it cannot maintain cardiac output and adequate tissue perfusion. Patients at risk for developing infections leading to septic shock include those who are hospitalized, have debilitating chronic illnesses, or have poor nutritional status. Septic shock does not usually present with a patient who presents with a traumatic injury. Anaphylactic shock is the result of a widespread hypersensitivity reaction from medications, blood administration, latex, foods, snake venom, and insect stings.Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 9. Discuss the risk factors, etiologies, and pathophysiologies of hypovolemic shock, cardiogenic shock, obstructive shock, and distributive shock.

Question 34Type: MCSAThe nurse suspects that a patient diagnosed with a myocardial infarction is developing cardiogenic shock when which of the following is assessed?

1. jugular vein distention2. warm extremities3. laryngospasm4. urticariaCorrect Answer: 1Rationale 1: Jugular vein distention is seen in cardiogenic shock.Rationale 2: Warm extremities are seen in early septic shock and anaphylactic shock.Rationale 3: Laryngospasm is seen in anaphylactic shock.Rationale 4: Urticaria is seen in anaphylactic shock.Global Rationale: Jugular vein distention is seen in cardiogenic shock. Warm extremities are seen in early septic shock and anaphylactic shock. Laryngospasm and urticaria are seen in anaphylactic shock.Cognitive Level: AnalyzingClient Need: Physiological Integrity


Question 35Type: MCSAA patient is diagnosed with a pneumothorax. The nurse realizes that unless this is treated, the patient is at risk for developing which of the following types of shock?

1. obstructive2. hypovolemic3. cardiogenic4. neurogenicCorrect Answer: 1Rationale 1: Obstructive shock is caused by an obstruction in the heart or great vessels that either impedes venous return or prevents effective cardiac pumping action. One cause of obstructive shock is impaired diastolic filling as seen in a pneumothorax.Rationale 2: Hypovolemic shock is seen in patients with a low circulating blood volume.Rationale 3: Cardiogenic shock can occur in patients who have experienced a myocardial infarction.Rationale 4: Neurogenic shock can occur in patients with spinal cord injuries.Global Rationale: Obstructive shock is caused by an obstruction in the heart or great vessels that either impedes venous return or prevents effective cardiac pumping action. One cause of obstructive shock is impaired diastolic filling as seen in a pneumothorax. Hypovolemic shock is seen in patients with a low circulating blood volume. Cardiogenic shock can occur in patients who have experienced a myocardial infarction. Neurogenic shock can occur in patients with spinal cord injuries.Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 9. Discuss the risk factors, etiologies, and pathophysiologies of hypovolemic shock, cardiogenic shock, obstructive shock, and distributive shock.

Question 36Type: MCSAAn elderly patient is diagnosed with E. coli in the blood stream. If not treated, the nurse realizes this patient is at risk for developing which of the following types of shock?

1. distributive2. obstructive3. hypovolemic4. anaphylacticCorrect Answer: 1Rationale 1: Distributive shock includes several types of shock that result from widespread vasodilatation and decreased peripheral resistance. As the blood volume does not change, relative hypovolemia results. One example of distributive shock is septic shock. Septic shock is one part of a progressive syndrome called systemic inflammatory response syndrome and is most often the result of gram-negative bacterial infections such as E. coli.Rationale 2: Obstructive shock is caused by an obstruction in the heart or great vessels that either impedes venous return or prevents effective cardiac pumping action.Rationale 3: Hypovolemic shock occurs with a decrease in circulating blood volume.Rationale 4: Anaphylactic shock occurs as the result of a widespread humorally mediated hypersensitivity reaction.Global Rationale: Distributive shock includes several types of shock that result from widespread vasodilatation and decreased peripheral resistance. As the blood volume does not change, relative hypovolemia results. One example of distributive shock is septic shock. Septic shock is one part of a progressive syndrome called systemic inflammatory response syndrome and is most often the result of gram-negative bacterial infections such as E. coli. Obstructive shock is caused by an obstruction in the heart or great vessels that either impedes venous return or prevents effective cardiac pumping action. Hypovolemic shock occurs with a decrease in circulating blood volume. Anaphylactic shock occurs as the result of a widespread humorally mediated hypersensitivity reaction.Cognitive Level: AnalyzingClient Need: Physiological Integrity


Question 37Type: MCSAWhich of the following interventions would be essential for the nurse to assess first for a patient admitted with severe facial injuries?

1. signs of stridor, cough, or respiratory distress2. blood pressure3. need for suctioning4. mouth for loose teeth or obvious problems with the mouthCorrect Answer: 1Rationale 1: The patient with multiple injuries is at great risk for developing airway obstruction and apnea. All of the choices are important; however, the most important intervention for the nurse to assess is to make sure the airway is patent and maintainable. The nurse should assess for manifestations of airway obstruction including stridor, tachypnea, bradypnea, cough, cyanosis, dyspnea, decreased or absent breath sounds, changes in oxygen levels, and changes in level of consciousness.Rationale 2: The blood pressure can be assessed after the patient is assessed for respiratory distress.Rationale 3: The need for suctioning can be determined after it has been determined that the patient has an adequate airway.Rationale 4: Assessment of the mouth can occur after determining that the patient has an adequate airway.Global Rationale: The patient with multiple injuries is at great risk for developing airway obstruction and apnea. All of the choices are important; however, the most important intervention for the nurse to assess is to make sure the airway is patent and maintainable. The nurse should assess for manifestations of airway obstruction including stridor, tachypnea, bradypnea, cough, cyanosis, dyspnea, decreased or absent breath sounds, changes in oxygen levels, and changes in level of consciousness. The blood pressure can be assessed after the patient is assessed for respiratory distress. The need for suctioning can be determined after it has been determined that the patient has an adequate airway. Assessment of the mouth can occur after determining that the patient has an adequate airway.Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 10. Use the nursing process as a framework for providing individualized care to patients experiencing trauma and shock.

Question 38Type: MCSAA patient who was a victim of rape six months ago comes to an outpatient clinic for the treatment of post-traumatic stress disorder. Which data collected during the patients assessment would indicate a manifestation associated with this disorder?

1. discussed severe nightmares related to the traumatic event2. denied anger or shock3. denied the need for drug or alcohol counseling4. stated that her family is very supportiveCorrect Answer: 1Rationale 1: Post-traumatic stress disorder is an intense, sustained emotional response to a disastrous event. It is characterized by emotions that range from anger to fear, and by flashbacks or psychic numbing. In the initial stage, the patient can be calm or might express feelings of anger, disbelief, terror, and shock. In the long-term phase, which begins anywhere from a few days to several months after the event, the patient often experiences flashbacks and nightmares of the traumatic event. The patient also might call on ineffective coping mechanisms, such as alcohol or drugs, and withdraw from relationships.Rationale 2: Feelings of anger and shock are associated with post-traumatic stress disorder.Rationale 3: Patients who suffer from post-traumatic stress disorder are more prone to using alcohol or drugs.Rationale 4: These patients usually withdraw from relationships.Global Rationale: Post-traumatic stress disorder is an intense, sustained emotional response to a disastrous event. It is characterized by emotions that range from anger to fear, and by flashbacks or psychic numbing. In the initial stage, the patient can be calm or might express feelings of anger, disbelief, terror, and shock. In the long-term phase, which begins anywhere from a few days to several months after the event, the patient often experiences flashbacks and nightmares of the traumatic event. The patient also might call on ineffective coping mechanisms, such as alcohol or drugs, and withdraw from relationships.Cognitive Level: AnalyzingClient Need: Psychosocial Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 10. Use the nursing process as a framework for providing individualized care to patients experiencing trauma and shock.

Question 39Type: MCSAThe nurse, planning care for a patient diagnosed with shock, would include which of the following interventions for the nursing diagnosis of Anxiety?

1. reduce stimuli and medicate for pain2. assess blood pressure and heart rate.3. monitor central venous pressure4. assess bowel soundsCorrect Answer: 1Rationale 1: Interventions appropriate for the nursing diagnosis of Anxiety include reducing stimuli to crease calm and facilitate rest and medicating for pain because pain precipitates or aggravates anxiety.Rationale 2: Assessing blood pressure and heart rate would be appropriate for the nursing diagnosis of Decreased Cardiac Output.Rationale 3: Monitoring central venous pressure would be appropriate for the nursing diagnosis of Altered Tissue Perfusion.Rationale 4: Assessing bowel sounds would be appropriate for the nursing diagnosis of Decreased Cardiac Output.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 10. Use the nursing process as a framework for providing individualized care to patients experiencing trauma and shock.

Question 40Type: MCSAA patient hospitalized with traumatic injuries has the nursing diagnosis of Impaired Physical Mobility. Which of the following interventions would be appropriate for this patient?

1. Provide active range of motion exercises to affected extremities once every eight hours.2. Turn and reposition every one hour.3. Remove antiembolic stockings for three hours every shift.4. Administer tetanus toxoid.Correct Answer: 1Rationale 1: The patient with traumatic injuries and the nursing diagnosis of Impaired Physical Mobility should have active range of motion exercises to the affected extremities once every eight hours.Rationale 2: The patient should be turned and repositioned every two hours.Rationale 3: Antiembolic stockings should be removed for one hour every shift.Rationale 4: Administering the tetanus toxoid would be appropriate for the nursing diagnosis of Risk for Infection.Global Rationale: The patient with traumatic injuries and the nursing diagnosis of Impaired Physical Mobility should have active range of motion exercises to the affected extremities once every eight hours. The patient should be turned and repositioned every two hours. Antiembolic stockings should be removed for one hour every shift. Administering the tetanus toxoid would be appropriate for the nursing diagnosis of Risk for Infection.Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 10. Use the nursing process as a framework for providing individualized care to patients experiencing trauma and shock.

Question 41Type: MCMAA patient is admitted with trauma to the integumentary system. Which of the following are types of skin trauma?

Standard Text: Select all that apply.1. cutaneous2. abrasion3. laceration4. contusionCorrect Answer: 2,3,4Rationale 1: Four specific injuries to the integument are contusions, abrasions, puncture wounds, and lacerations. Cutaneous is a term used to refer to the integument. It is not associated with trauma to the skin.Rationale 2: Four specific injuries to the integument are contusions, abrasions, puncture wounds, and lacerations.Rationale 3: Four specific injuries to the integument are contusions, abrasions, puncture wounds, and lacerations.Rationale 4: Four specific injuries to the integument are contusions, abrasions, puncture wounds, and lacerations.Global Rationale: Four specific injuries to the integument are contusions, abrasions, puncture wounds, and lacerations. Cutaneous is a term used to refer to the integument. It is not associated with trauma to the skin.Cognitive Level: ApplyingClient Need: Physiological Integrity


Question 42Type: MCMAA trauma patient is being assessed with the Champion Revised Scoring System. What are the elements of this scoring system?

Standard Text: Select all that apply.1. diastolic blood pressure2. heart rate3. Glasgow coma scale4. systolic blood pressure5. respiratory rateCorrect Answer: 3,4,5Rationale 1: Diastolic blood pressure is not included in the Champion Revised Scoring System.Rationale 2: Heart rate is not included in the Champion Revised Scoring System.Rationale 3: The Champion Revised Scoring System analyzes three elements: the Glasgow Coma Scale, systolic blood pressure, and respiratory rate. The patient then receives a total score. The highest score is 12.Rationale 4: The Champion Revised Scoring System analyzes three elements: the Glasgow Coma Scale, systolic blood pressure, and respiratory rate. The patient then receives a total score. The highest score is 12.Rationale 5: The Champion Revised Scoring System analyzes three elements: the Glasgow Coma Scale, systolic blood pressure, and respiratory rate. The patient then receives a total score. The highest score is 12.Global Rationale: The Champion Revised Scoring System analyzes three elements: the Glasgow Coma Scale, systolic blood pressure, and respiratory rate. The patient then receives a total score. The highest score is 12. Although the diastolic blood pressure and heart rate are a part of the patients assessment, they are not included in the Champion Revised Scoring System.Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 5. Discuss diagnostic tests used in assessing patients experiencing trauma.

Question 43Type: MCHSA patient comes to the emergency department with bright red blood flowing from the lower right arm. Place an X over the artery used to control the bleeding.

Correct Answer: Rationale : Direct pressure is applied over the artery supplying the lower arm. The radial artery is not appropriate as it is in the lower arm and is affected by the trauma. No other arterial pressure point will control the bleeding of the lower arm.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 4. Discuss causes, effects, and initial management of trauma.

Question 44Type: MCHSDuring shock, the reticuloendothelial Kupffer cells can be destroyed. Place an X on the location of these cells.

Correct Answer: Rationale : During shock, the blood supply to the liver is impaired from constriction of the blood supply to the liver. The Kupffer cells (phagocytes that destroy bacteria) are destroyed and bacteria can proliferate.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity


Question 45Type: MCSAIn reviewing the patient manifestations (see above), the nurse recognizes the patient is in which stage of shock?

1. compensated2. mild3. moderate4. severeCorrect Answer: 3Rationale 1: With compensated shock, the blood loss is 750 mL with up to 15% blood loss. Other indicators are normal or increased, the patient is only slightly anxious.Rationale 2: Mild shock has a blood loss of 7501500 mL, 15%30% blood volume loss, heart rate >100, blood pressure is normal, the pulse pressure is decreased, the capillary refill and respiratory rate are slightly increased, urine output is 2030 mL/h and the patient is mildly anxious to agitated.Rationale 3: The manifestations found in moderate shock are: blood loss of 15002000 mL, 30%40% blood loss, the heart rate is >120, the blood pressure and pulse pressure are decreased, capillary refill is increased over the normal, the patient has moderate tachypnea, the urinary output is below normal, and the mental status is altered.Rationale 4: In severe shock, the patients condition has deteriorated markedly with over 2000 mL blood loss and >40% loss of blood volume.Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological Integrity


Question 46Type: MCSAA posttrauma patient has these laboratory results (see above). Based on analyzing of the laboratory results, the nurse

1. suspects distributive shock.2. recognizes the results as normal.3. places the patient in contact precautions.4. prepares for insertion of a central venous catheter.Correct Answer: 2Rationale 1: Distributive shock would have a decrease in blood volume because of relative hypovolemia.Rationale 2: All of the laboratory values are within normal limits. The WBC ranges from 5 to 10 thousand, neutrophils 55%-70%, monocytes 2%-8%, eosinophils 1%-4%, and lymphocytes 20%-40%.Rationale 3: The patient does not have an infection.Rationale 4: A central venous catheter is not required for this patient.Global Rationale: All of the laboratory values are within normal limits. The WBC ranges from 5 to 10 thousand, neutrophils 55%-70%, monocytes 2%-8%, eosinophils 1%-4%, and lymphocytes 20%-40%. Distributive shock would have a decrease in blood volume because of relative hypovolemia; the patient does not have an infection, therefore does not need contact precautions and a central venous catheter is not needed in this situation.Cognitive Level: ApplyingClient Need: Physiological Integrity


Question 47Type: FIBA patient is to receive nitroglycerin (Tridil) 10 mcg/min. The medication strength is 50 mg/250 mL. The IV rate will be __________(fill in the blank).

Standard Text: Correct Answer: 3Rationale : 10 mcg is changed to 0.01 mg by moving the decimal three places to the left. The problem is then 0.01 mg/min = x mL/h0. 01 mg/min x 60/60 = 0.6 mg/60 min = 0.6 mg/1h0. 6 mg/h = xmL/h0. 6 mg/x mL = 50 mg/250 mL50. = 150x = 3Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: EvaluationLearning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids.

Question 48Type: MCMAA patient has received 145 mL of blood and complains of chills. The nurse will also assess for which of the following?

Standard Text: Select all that apply.1. bradypnea2. urticaria3. fever4. hypertension5. lumbar painCorrect Answer: 2,3,5Rationale 1: Patients who are having a hemolytic reaction to blood will experience dyspnea, urticaria, fever, hypotension, lumbar pain, abdominal pain, chills, and nausea and vomiting. The patients respiratory rate will not decrease.Rationale 2: Patients who are having a hemolytic reaction to blood will experience dyspnea, urticaria, fever, hypotension, lumbar pain, abdominal pain, chills, and nausea and vomiting.Rationale 3: Patients who are having a hemolytic reaction to blood will experience dyspnea, urticaria, fever, hypotension, lumbar pain, abdominal pain, chills, and nausea and vomiting.Rationale 4: Patients who are having a hemolytic reaction to blood will experience dyspnea, urticaria, fever, hypotension, lumbar pain, abdominal pain, chills, and nausea and vomiting. Their blood pressure will not be elevated.Rationale 5: Patients who are having a hemolytic reaction to blood will experience dyspnea, urticaria, fever, hypotension, lumbar pain, abdominal pain, chills, and nausea and vomiting.Global Rationale: Patients having a hemolytic reaction to blood will experience dyspnea, urticaria, fever, hypotension, lumbar pain, abdominal pain, chills, and nausea and vomiting. Symptoms occur because of clumping of the RBCs, which block capillaries and the action of macrophages engulfing the clumped RBCs. The activity of the macrophages releases free hemoglobin. The patient will not have hypertension and will have tachypnea instead of bradypnea.Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids.

Question 49Type: MCMAA patient in hypovolemic shock is receiving a colloid solution (plasma expander). The rate of infusion is slowed when the nurse assesses which of the following?

Standard Text: Select all that apply.1. a prothrombin time of 13.5 seconds2. jugular vein distension3. tenting of skin4. increased central venous pressure5. auscultation of crackles and wheezesCorrect Answer: 2,4,5Rationale 1: A prothrombin time of 13.5 seconds is within normal range.Rationale 2: Jugular vein distension, increased central venous pressure, and crackles and wheezes indicate circulatory overload and pulmonary edema.Rationale 3: Tenting of the skin is associated with dehydration.Rationale 4: Jugular vein distension, increased central venous pressure, and crackles and wheezes indicate circulatory overload and pulmonary edema.Rationale 5: Jugular vein distension, increased central venous pressure, and crackles and wheezes indicate circulatory overload and pulmonary edema.Global Rationale: Jugular vein distension, increased central venous pressure, and crackles and wheezes indicate circulatory overload and pulmonary edema. The rate of infusion would be slowed and the physician notified. Tenting of skin would indicate dehydration and the need for more fluid replacement.Cognitive Level: ApplyingClient Need: Physiological Integrity


Question 50Type: SEQAn on-the-scene rapid assessment is completed on the trauma victim. Place the assessments in order of importance.

Standard Text: Click and drag the options below to move them up or down.Choice 1. assessment for obvious injuriesChoice 2. Champion Revised Trauma Scoring systemChoice 3. airway and breathing assessmentChoice 4. circulation assessmentChoice 5. level of consciousness and pupillary functionCorrect Answer: 4,5,1,2,3 Rationale 1: The fourth step is to assess for obvious injuries.Rationale 2: The last step is use the Champion Revised Trauma Scoring system.Rationale 3: The first step is to assess the patients airway and breathing.Rationale 4: The second step is to assess the patients circulatory system.Rationale 5: The third step is to assess the patients level of consciousness and pupillary function.Global Rationale: The airway and breathing assessment is completed first with the circulatory assessment second as this follows the principle of the ABCs. The airway must be patent with adequate breathing to provide oxygen to the vital organs. The level of consciousness and pupillary function will indicate any head injury/spinal cord injury that must be immobilized before transport. The Champion Revised Trauma Scoring system will indicate the chance of survival for the trauma victim based on the Glasgow Coma Scale, systolic blood pressure, and respiratory rate.Cognitive Level: ApplyingClient Need: Physiological Integrity


LeMone/Burke/Bauldoff, Medical-Surgical Nursing 5th Edition Test Bank

Copyright 2011 by Pearson Education, Inc.

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