You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these
... [Show More] patients:
a. An ambulatory, dazed 25-year-old male with a bandaged head wound
b. An irritable infant with a fever, petechiae, and nuchal rigidity
c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
d. A 50-year-old female with moderate abdominal pain and occasional vomiting.
1.) A B D C
2.) B A D C
3.) C D B A
4.) C B A D
2.) B A D C
Rationale:
An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24 - 48 hours if necessary.
In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey?
a.) Complete set of vital signs
b.) Palpation and auscultation of the abdomen
c.) Brief neurologic assessment
d.) Initiation of pulse oximetry
c.) Brief neurologic assessment
Rationale:
A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey.
You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform.
a. Perform the chin lift or jaw thrust maneuver.
b. Establish unresponsiveness.
c. Initiate cardiopulmonary resuscitation (CPR).
d. Call for help and activate the code team.
e. Instruct a nursing assistant to get the crash cart.
1.) A B C E D
2.) B D A C E
3.) C A B E D
4.) D C B E A
5.) E C D B A
2.) B D A C E
Rationale:
Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives.
A client with trauma to the chest develops a tension pneumothorax. After a needle thorocostomy is performed the nurse would expect:
a.) an increase in blood pressure.
b.) a decrease in blood pressure.
c.) an increase in jugular venous distension.
d.) a decrease in level of consciousness.
a.) an increase in blood pressure.
Rationale:
Clients presenting with tension pneumothorax would exhibit hypotension, jugular venous distension, and decreasing level of consciousness. An increase in blood pressure should result after a thoracostomy is performed.
A pediatric client is admitted to the neuro ICU with a closed-head injury sustained after falling out of a tree house. The mechanisms of injury this young client most likely sustained would be:
a.) Acceleration
b.) Penetrating
c.) Rotational
d.) Deceleration
d.) Deceleration
Rationale:
Deceleration injury occurs when the brain stops rapidly in the cranial vault. As the skull ceases movement, the brain continues to move until it hits the skull. The force of deceleration causes injury at the site of impact. An example of this is a victim of a fall.
A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessments should the nurse make?
A.) Observe the color of the fingers
B.) Palpate the radial pulse under the cast
C.) Check the cast for odor and drainage
D.) Evaluate the response to analgesics
D.) Evaluate the response to analgesics
A client presents in the emergency department after falling from a roof. A fracture of the femoral neck is suspected. Which of these assessments best support this diagnosis?
A.) The client reports pain in the affected leg
B.) A large hematoma is visible in the affected extremity
C.) The affected extremity is shortened, adducted, and extremely rotated
D.) The affected extremity is edematous
C.) The affected extremity is shortened, adducted, and extremely rotated
When admitting a client with a fractured extremity, the nurse would focus the assessment on which of the following first?
a.) The area proximal to the fracture
b.) The actual fracture site
c.) The area distal to the fracture
d.) The opposite extremity for baseline comparison
c.) The area distal to the fracture
Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus?
a.) Acute respiratory distress syndrome
b.) Migraine like headaches
c.) Numbness in the right leg
d.) Muscle spasms in the right thigh
a.) Acute respiratory distress syndrome
Following x-rays of an injured wrist, the patient is informed that it is badly sprained. In teaching the patient to care for the injury, the nurse tells the patient to
a.) apply a heating pad to reduce muscle spasms.
b.) wear an elastic compression bandage continuously.
c.) use pillows to keep the arm elevated above the heart.
d.) gently exercise the joint to prevent muscle shortening.
c.) use pillows to keep the arm elevated above the heart.
Rationale:
Elevation of the arm will reduce the amount of swelling and pain. For the first 24 to 48 hours, cold packs are used to reduce swelling. Compression bandages are not left on continuously. The wrist should be rested and kept immobile to prevent further swelling or injury.
A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the patient's symptoms are most likely related to fat embolism when assessment of the patient reveals
a.) a blood pressure of 100/65 mm Hg.
b.) anxiety, restlessness, and confusion.
c.) warm, reddened areas in the calf.
d.) pinpoint red areas on the upper chest.
d.) pinpoint red areas on the upper chest.
Rationale:
The presence of petechiae helps distinguish fat embolism from other problems. The other symptoms might occur with fat embolism but could also occur with other postoperative complications such as bleeding, myocardial infarction, venous thrombosis, or hypoxemi [Show Less]