Chapter 72 Nursing School Test Banks

 

1.

Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below?

A)

A patient with a blunt chest trauma with some difficulty breathing

B)

A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar

C)

A patient with a possible fractured tibia with adequate pedal pulses

D)

A patient with an acute onset of confusion

Ans:

A

Feedback:

The patient with blunt chest trauma possibly has a compromised airway. Establishment and maintenance of a patent airway and adequate ventilation is prioritized over other health problems, including skeletal injuries and changes in cognition.

2.

The nurse observes that the family members of a patient who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family?

A)

Anxiety and denial

B)

Remorse and guilt

C)

Anger

D)

Grief

Ans:

B

Feedback:

Remorse and guilt are natural processes of the stages of a crisis and should be facilitated for the family members to process the crisis. The familys sense of blame and responsibility are more suggestive of guilt than anger, grief, or anxiety.

3.

A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what?

A)

Liver

B)

Small bowel

C)

Stomach

D)

Large bowel

Ans:

B

Feedback:

Penetrating abdominal wounds have a high incidence of injury to hollow organs, especially the small bowel. The liver is also injured frequently, but it is a solid organ.

4.

A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action?

A)

Perform a rapid physical assessment.

B)

Initiate health education.

C)

Perform diagnostic imaging.

D)

Establish the circumstances of the accident.

Ans:

A

Feedback:

Once immediate threats to life have been corrected, a rapid physical examination is done to identify injuries and priorities of treatment. Health education is initiated later in the care process and diagnostic imaging would take place after a rapid physical assessment. It is not the care teams responsibility to determine the circumstances of the accident.

5.

The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses who provide care in a desert region. The educator should describe what sign or symptom?

A)

Hypertension with a wide pulse pressure

B)

Anhidrosis

C)

Copious diuresis

D)

Cheyne-Stokes respirations

Ans:

B

Feedback:

Heat stroke is manifested by anhidrosis confusion, bizarre behavior, coma, elevated body temperature, hot dry skin, tachypnea, hypotension, and tachycardia. This health problem is not associated with anhidrosis or Cheyne-Stokes respirations.

6.

A patient is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The patient is alert and oriented. What is the care teams most appropriate treatment?

A)

Administering syrup of ipecac

B)

Performing a gastric lavage

C)

Giving milk to drink

D)

Referring to psychiatry

Ans:

C

Feedback:

A patient who has swallowed an acidic substance, such as toilet bowl cleaner, may be given milk or water to drink for dilution. Gastric lavage must be performed within 1 hour of ingestion. A psychiatric consult may be considered once the patient is physically stable and it is deemed appropriate by the physician. Syrup of ipecac is no longer used in clinical settings.

7.

A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action?

A)

Check the patients blood glucose level.

B)

Assess for a documented history of major depression.

C)

Determine whether the patient has ingested a corrosive substance.

D)

Arrange for assessment of serum potassium levels.

Ans:

A

Feedback:

Hypoglycemia can mimic alcohol intoxication and should be assessed in a patient suspected of alcohol intoxication. Potassium imbalances, depression, and poison ingestion are not noted to mimic the characteristic signs and symptoms of alcohol intoxication.

8.

The paramedics bring a patient who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim?

A)

Respect the patients privacy during assessment.

B)

Shave all pubic hair for laboratory analysis.

C)

Place items for evidence in plastic bags.

D)

Bathe the patient before the examination.

Ans:

A

Feedback:

The patients privacy and sensitivity must be respected, because the patient will be experiencing a stress response to the assault. Pubic hair is combed or trimmed for sampling. Paper bags are used for evidence collection because plastic bags retain moisture, which promotes mold and mildew that can destroy evidence. Bathing the patient before the examination would destroy or remove key evidence.

9.

A patient with a history of major depression is brought to the ED by her parents. Which of the following nursing actions is most appropriate?

A)

Noting that symptoms of physical illness are not relevant to the current diagnosis

B)

Asking the patient if she has ever thought about taking her own life

C)

Conducting interviews in a brief and direct manner

D)

Arranging for the patient to spend time alone to consider her feelings

Ans:

B

Feedback:

Establishing if the patient has suicidal thoughts or intents helps identify the level of depression and intervention. Physical symptoms are relevant and should be explored. Allow the patient to express feelings, and conduct the interview at a comfortable pace for the patient. Never leave the patient alone, because suicide is usually committed in solitude.

10.

A triage nurse is talking to a patient when the patient begins choking on his lunch. The patient is coughing forcefully. What should the nurse do?

A)

Stand him up and perform the abdominal thrust maneuver from behind.

B)

Lay him down, straddle him, and perform the abdominal thrust maneuver.

C)

Leave him to get assistance.

D)

Stay with him and encourage him, but not intervene at this time.

Ans:

D

Feedback:

If the patient is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the patient standing. If the patient is unconscious, the nurse should lay the patient down. A nurse should never leave a choking patient alone.

11.

You are a floor nurse caring for a patient with alcohol withdrawal syndrome. What would be an appropriate nursing action to minimize the potential for hallucinations?

A)

Engage the patient in a process of health education.

B)

Administer opioid analgesics as ordered.

C)

Place the patient in a private, well-lit room.

D)

Provide television or a radio as therapeutic distraction

Ans:

C

Feedback:

The patient should be placed in a quiet single room with lights on and in a calm nonstressful environment. TV and radio stimulation should be avoided. Analgesics are not normally necessary, and would potentially contribute to hallucinations. Health education would be inappropriate while the patient is experiencing acute withdrawal.

12.

An obtunded patient is admitted to the ED after ingesting bleach. The nurse should prepare to assist with what intervention?

A)

Prompt administration of an antidote

B)

Gastric lavage

C)

Administration of activated charcoal

D)

Helping the patient drink large amounts of water

Ans:

D

Feedback:

The patient who has ingested a corrosive poison, such as bleach, is given water or milk to drink for dilution. Gastric lavage is not used to treat ingestion of corrosives and activated charcoal is ineffective. There is no antidote for a corrosive substance such as bleach.

13.

A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient?

A)

Assessing the patients oral temperature frequently

B)

Ensuring continuous ECG monitoring

C)

Massaging the patients skin surfaces to promote circulation

D)

Administering bronchodilators by nebulizer

Ans:

B

Feedback:

A hypothermic patient requires continuous ECG monitoring and assessment of core temperatures with an esophageal probe, bladder, or rectal thermometer. Massage is not performed and bronchodilators would normally be insufficient to meet the patients respiratory needs.

14.

A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding?

A)

Absence of bruising at contusion sites

B)

Rapid pulse and decreased capillary refill

C)

Increased BP with narrowed pulse pressure

D)

Sudden diaphoresis

Ans:

B

Feedback:

The nurse would anticipate that the pulse would increase and BP would decrease. Urine output would also decrease. An absence of bruising and the presence of diaphoresis would not suggest internal hemorrhage.

15.

A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patients peritoneum, the nurse should anticipate what diagnostic test?

A)

Radiograph

B)

Computed tomography (CT) scan

C)

Complete blood count (CBC)

D)

Barium swallow

Ans:

B

Feedback:

CT scan of the abdomen, diagnostic peritoneal lavage, and abdominal ultrasound are appropriate diagnostic tools to assess intra-abdominal injuries. X-rays do not yield sufficient data and a CBC would not reveal the presence of intraperitoneal injury.

16.

A patient is brought to the ER in an unconscious state. The physician notes that the patient is in need of emergency surgery. No family members are present, and the patient does not have identification. What action by the nurse is most important regarding consent for treatment?

A)

Ask the social worker to come and sign the consent.

B)

Contact the police to obtain the patients identity.

C)

Obtain a court order to treat the patient.

D)

Clearly document LOC and health status on the patients chart.

Ans:

D

Feedback:

When patients are unconscious and in critical condition, the condition and situation should be documented to administer treatment quickly and timely when no consent can be obtained by usual routes. A social worker is not asked to sign the consent. Finding the patients identity is not a priority. Obtaining a court order would take too long.

17.

A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions?

A)

Insert an oropharyngeal airway.

B)

Perform the jaw thrust maneuver.

C)

Perform endotracheal intubation.

D)

Perform a cricothyroidotomy.

Ans:

C

Feedback:

Endotracheal tubes are used in cases when the patient cannot be ventilated with an oropharyngeal airway, which is used in patients who are breathing spontaneously. The jaw thrust maneuver does not establish an airway and cricothyroidotomy would be performed as a last resort.

18.

A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient?

A)

Ambulate the patient to expel flatus.

B)

Place the patient in a high Fowlers position.

C)

Immobilize the patient on a backboard.

D)

Place the patient in a left lateral position.

Ans:

C

Feedback:

When admitted for blunt trauma, patients must be immobilized until spinal injury is ruled out. Ambulation, side-lying, and upright positioning would be contraindicated until spinal injury is ruled out.

19.

A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the patients frostbite?

A)

Immerse affected extremities in water slightly above normal body temperature.

B)

Immerse the patients frostbitten extremities in the warmest water the patient can tolerate.

C)

Gently massage the patients frozen extremities in between water baths.

D)

Perform passive range-of-motion exercises of the affected extremities to promote circulation.

Ans:

A

Feedback:

Frozen extremities are usually placed in a 37C to 40C (98.6F to 104F) circulating bath for 30- to 40-minute spans. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

20.

A patient with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the patients injuries?

A)

Myocardial infarction

B)

Hypoglycemia

C)

Hemorrhage

D)

Peritonitis

Ans:

C

Feedback:

The signs and symptoms the patient is experiencing suggest a volume deficit from an internal bleed. That the symptoms follow an acute injury suggests hemorrhage rather than myocardial infarction or hypoglycemia. Peritonitis would be an unlikely result of a femoral fracture.

21.

A patient who has been diagnosed with cholecystitis is being discharged home from the ED to be scheduled for surgery later. The patient received morphine during the present ED admission and is visibly drowsy. When providing health education to the patient, what would be the most appropriate nursing action?

A)

Give written instructions to patient.

B)

Give verbal instructions to one of the patients family members.

C)

Telephone the patient the next day with verbal instructions.

D)

Give verbal and written instructions to patient and a family member.

Ans:

D

Feedback:

Before discharge, verbal and written instructions for continuing care are given to the patient and the family or significant others. Discharge teaching is completed prior to the patient leaving the ED, so phoning the patient the next day in not acceptable.

22.

A patient is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply.

A)

Ascites

B)

Rebound tenderness

C)

Changes in bowel sounds

D)

Muscular rigidity

E)

Copious diarrhea

Ans:

B, C, D

Feedback:

Signs of peritoneal irritation include abdominal distention, involuntary guarding, tenderness, pain, muscular rigidity, or rebound tenderness along with changes in bowel sounds. Diarrhea and ascites are not signs of peritoneal irritation.

23.

A patient who attempted suicide being treated in the ED is accompanied by his mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following action?

A)

Refer the family to psychiatry in order to provide them with support.

B)

Explore the causes of the patients suicide attempt with the family.

C)

Encourage the family to participate in the bedside care of the patient.

D)

Ensure that the family receives appropriate crisis intervention services.

Ans:

D

Feedback:

It is essential that family crisis intervention services are available for families of ED patients. It would be inappropriate and insensitive to explore causes of the patients suicide attempt with the family. Family participation in bedside care is often impractical in the ED setting. Psychiatry is not the normal source of psychosocial support and crisis intervention.

24.

A patient is admitted to the ED after being involved in a motor vehicle accident. The patient has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care?

A)

Control the patients hemorrhage.

B)

Assess for cognitive effects of the injury.

C)

Splint the patients fractures.

D)

Assess the patients neurologic status.

Ans:

A

Feedback:

After establishing airway and ventilation, the team should evaluate and restore cardiac output by controlling hemorrhage. This must precede neurologic assessments and treatment of skeletal injuries.

25.

A patient with multiple trauma is brought to the ED by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this patients care?

A)

Intubating the patient

B)

Notifying family members

C)

Ensuring IV access

D)

Delivering specimens to the laboratory

Ans:

C

Feedback:

ED nursing responsibilities include ensuring airway and IV access. Nurses are not normally responsible for notifying family members. Nurses collect specimens, but are not responsible for their delivery. Physicians or other team members with specialized training intubate the patient.

26.

A patient has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the patients bladder is distended. What is the nurses most appropriate action?

A)

Withhold fluids from the patient.

B)

Perform intermittent urinary catheterization.

C)

Insert a narrow-gauge indwelling urinary catheter.

D)

Await orders following the urologists assessment.

Ans:

D

Feedback:

Urethral catheter insertion when a possible urethral injury is present is contraindicated; a urology consultation and further evaluation of the urethra are required. The nurse would withhold fluids, but urologic assessment is the priority.

27.

The triage nurse is working in the ED. A homeless person is admitted during a blizzard with complaints of being unable to feel his feet and lower legs. Core temperature is noted at 33.2C (91.8F). The patient is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurses priority in the care of this patient?

A)

Addressing the patients hypothermia

B)

Addressing the patients frostbite in his lower extremities

C)

Addressing the patients alcohol intoxication

D)

Addressing the patients malnutrition

Ans:

A

Feedback:

The patient may also have frostbite, but hypothermia takes precedence in treatment because it is systemic rather than localized. The alcohol abuse and the alteration in nutrition do not take precedence over the treatment of hypothermia because both problems are a less acute threat to the patients survival.

28.

A patient is brought to the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temperature of 40.1C (104.2F). What would be the priority nursing action for this patient?

A)

Monitor cardiovascular effects.

B)

Administer antipyretics.

C)

Ensure airway and ventilation.

D)

Prevent seizure activity.

Ans:

C

Feedback:

Although all of the listed actions may be necessary for this patients care, the priority is to establish a patent airway and adequate ventilation.

29.

A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply.

A)

Dysrhythmias

B)

Hypothermia

C)

Hypotension

D)

Hyperglycemia

E)

Delirium

Ans:

A, C, E

Feedback:

The patient is assessed for signs and symptoms of fluid and electrolyte imbalances, including lethargy, rapid pulse rate, fever, oliguria, anuria, hypotension, and delirium. Hyperglycemia and hypothermia are not typically associated with fluid and electrolyte imbalances.

30.

The nurse is caring for a patient admitted with a drug overdose. What is the nurses priority responsibility in caring for this patient?

A)

Support the patients respiratory and cardiovascular function.

B)

Provide for the safety of the patient.

C)

Enhance clearance of the offending agent.

D)

Ensure the safety of the staff.

Ans:

A

Feedback:

Treatment goals for a patient with a drug overdose are to support the respiratory and cardiovascular functions, to enhance clearance of the agent, and to provide for safety of the patient and staff. Of these responsibilities, however, support of vital physiologic function is a priority.

31.

A patient is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the patients cardiopulmonary status, the nurse should prepare to perform what intervention?

A)

Administer a bolus of lactated Ringers.

B)

Administer naloxone hydrochloride (Narcan).

C)

Insert an indwelling urinary catheter.

D)

Perform a focused neurologic assessment.

Ans:

B

Feedback:

Narcan is an opioid antagonist that is administered for the treatment of narcotic overdoses. There is no definitive need for a urinary catheter or for a bolus of lactated Ringers. The patients basic neurologic status should be ascertained during the rapid assessment, but a detailed examination would be take precedence over administration of an antidote.

32.

A patient is being treated for bites that she suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action?

A)

Apply a dressing saturated with chlorhexidine.

B)

Wash the bites with soap and water.

C)

Arrange for the patient to receive a hepatitis B vaccination.

D)

Assess the patients immunization history.

Ans:

B

Feedback:

After forensic evidence has been gathered, cleansing with soap and water is necessary, followed by the administration of antibiotics and tetanus toxoid as prescribed. The patients immunization history does not directly influence the course of treatment and hepatitis B vaccination is not indicated. Chlorhexidine bandages are not recommended.

33.

A nurse is caring for a patient who has been the victim of sexual assault. The nurse documents that the patient appears to be in a state of shock, verbalizing fear, guilt, and humiliation. What phase of rape trauma syndrome is this patient most likely experiencing?

A)

Reorganization phase

B)

Denial phase

C)

Heightened anxiety phase

D)

Acute disorganization phase

Ans:

D

Feedback:

The acute disorganization phase may manifest as an expressed state in which shock, disbelief, fear, guilt, humiliation, anger, and other such emotions are encountered. These varied responses to the assault are not associated with a denial, heightened anxiety, or reorganization phase.

34.

The ED nurse is planning the care of a patient who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal?

A)

Encouraging the patient to gain a sense of control over his or her life

B)

Collecting sufficient evidence to secure a criminal conviction

C)

Helping the patient understand that this will not happen again

D)

Encouraging the patient to verbalize what happened during the assault

Ans:

A

Feedback:

The goals of management are to provide support, to reduce the patients emotional trauma, and to gather available evidence for possible legal proceedings. All of the interventions are aimed at encouraging the patient to gain a sense of control over his or her life. The patients well-being should be considered a priority over criminal proceedings. No health professional can guarantee the patients future safety and having the patient verbalize the event is not a priority.

35.

The ED nurse admitting a patient with a history of depression is screening the patient for suicide risk. What assessment question should the nurse ask when screening the patient?

A)

How would you describe your mood over the past few days?

B)

Have you ever thought about taking your own life?

C)

How do you think that your life is most likely to end?

D)

How would you rate the severity of your depression right now on a 10-point scale?

Ans:

B

Feedback:

The nurse should address the patients possible plans for suicide in a direct yet empathic manner. The nurse should avoid oblique or indirect references to suicide and should not limit questions to the patients depression.

36.

A patient is brought to the ED by family members who tell the nurse that the patient has been exhibiting paranoid, agitated behavior. What should the nurse do when interacting with this patient?

A)

Keep the patient in a confined space.

B)

Use therapeutic touch appropriately.

C)

Give the patient honest answers about likely treatment.

D)

Attempt to convince the patient that his or her fears are unfounded.

Ans:

C

Feedback:

The nurse should offer appropriate and honest explanations in order to foster rapport and trust. Confinement is likely to cause escalation, as is touching the patient. The nurse should not normally engage in trying to convince the patient that his or her fears are unjustified, as this can also cause escalation.

37.

A patient is brought to the ED by two police officers. The patient was found unconscious on the sidewalk, with his face and hands covered in blood. At present, the patient is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the patient in restraints. What action should the nurse perform when the patient is restrained?

A)

Frequently assess the patients skin integrity.

B)

Inform the patient that he is likely to be charged with assault.

C)

Avoid interacting with the patient until the restraints are removed.

D)

Take the opportunity to perform a full physical assessment.

Ans:

A

Feedback:

It is important to assess skin integrity when physical restraints are used. Criminal charges are not the responsibility of the nurse and the nurse should still interact with the patient. A full physical assessment, however, would likely be delayed until the patient is not combative.

38.

An 83-year-old patient is brought in by ambulance from a long-term care facility. The patients symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage. Why would this be true?

A)

Older adults may have an altered response to treatment.

B)

Older adults are often reluctant to adhere to prescribed treatment.

C)

Older adults have difficulty giving a health history.

D)

Older adults often stigmatize their peers who use the ED.

Ans:

A

Feedback:

Emergencies in this age group may be more difficult to manage because elderly patients may have an atypical presentation, an altered response to treatment, a greater risk of developing complications, or a combination of these factors. The elderly patient may perceive the emergency as a crisis signaling the end of an independent lifestyle or even resulting in death. Stigmatization and nonadherence to treatment are not commonly noted. Older adults do not necessarily have difficulty giving a health history.

39.

An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patients acuity as well as what other variable?

A)

The likelihood of a repeat visit to the ED in the next 7 days

B)

The resources that the patient is likely to require

C)

The patients or insurers ability to pay for care

D)

Whether the patient is known to ED staff from previous visits

Ans:

B

Feedback:

With the ESI, patients are assigned to triage levels based on both their acuity and their anticipated resource needs. Ability to pay, the likelihood of repeat visits, and the history of prior visits are not explicitly considered.

40.

A 23-year-old woman is brought to the ED complaining of stomach cramps, nausea, vomiting, and diarrhea. The care team suspects food poisoning. What is the key to treatment in food poisoning?

A)

Administering IV antibiotics

B)

Assessing immunization status

C)

Determining the source and type of food poisoning

D)

Determining if anyone else in the family is ill

Ans:

C

Feedback:

Determining the source and type of food poisoning is essential to treatment, and is more important than determining other sick family members. Antibiotics are not normally indicated and immunizations are not relevant to diagnosis or treatment of food poisoning.

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