Chapter 82: Management of Clients in the Emergency Department Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 82: Management of Clients in the Emergency Department

MULTIPLE CHOICE

1. An unconscious client is brought to the emergency department (ED) by ambulance following a car accident. Without a family member to give informed consent, the nurse should

a.

begin treatment of the client under the doctrine of implied emergency consent.

b.

have a hospital administrator sign the consent form.

c.

request the physician to sign the consent form.

d.

wait until a family member is contacted before treating the client.

ANS: A

When a client is unable to give consent or is unconscious, emergency treatment can be provided under the doctrine of implied consent, which assumes that the client would consent to treatment to prevent death or disability if the client were so able.

DIF: Comprehension/Understanding REF: p. 2191 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Legal Rights and Responsibilities

2. A client is brought to the emergency department (ED) in critical condition after a car crash. The clients family is distraught. To best help this family, the ED nurse should first

a.

assist the family to make phone calls to other family members.

b.

call the hospital chaplain or social worker to be with the family.

c.

help the family understand the reality of the situation.

d.

tell the family they must stay in the waiting room until they calm down.

ANS: C

The family needs a clear understanding of their loved ones condition before proceeding on to calling other family members and perhaps giving them incorrect information. Having a good understanding of the situation can also help the family calm down. A chaplain or social worker can be an effective adjunct, but the ED nurse is primarily responsible for providing information to the family. Making the family stay in the waiting room until they calm down may actually increase their agitation, although it is acceptable to give them guidelines for behaviors.

DIF: Application/Applying REF: p. 2213 OBJ: Intervention

MSC: Psychosocial Integrity Coping Mechanisms

3. The ED triage nurse identifies the client who can have treatment delayed for a few hours as the client with a

a.

avulsed (knocked-out) tooth.

b.

broken finger.

c.

head injury from a fall.

d.

large laceration that needs suturing.

ANS: A

This client requires treatment, but life/limb/vision is not threatened if care cannot be provided within 1 to 2 hours. The other injuries would require more rapid care to prevent future problems or possible complications.

DIF: Analysis/Analyzing REF: p. 2194 OBJ: Assessment

MSC: Psychosocial Integrity Reduction of Risk Potential-Potential for Alteration in Body Systems

4. A client is brought to the emergency department complaining of severe chest pain. The triage nurse assigns this client the triage category of

a.

emergent.

b.

non-urgent.

c.

urgent.

d.

vital.

ANS: A

In the emergent category, the client must be treated immediately; otherwise, life/limb/vision is threatened. The client having chest pain must be evaluated immediately for a myocardial infarction. The non-urgent client has no time restrictions on treatment. The urgent client does not have a threat to life/limb/vision and care can be provided within 1-2 hours. Vital is not a triage classification.

DIF: Analysis/Analyzing REF: p. 2194 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Alteration in Body Systems

5. When a client is admitted to the ED with respiratory distress and rapid-sequence induction (RSI) is needed to intubate the client, the nurse should first

a.

apply nasal oxygen.

b.

establish intravenous (IV) access.

c.

hyperventilate with 50% oxygen.

d.

insert a nasogastric tube.

ANS: B

RSI involves (1) establishing venous access, (2) hyperventilating the client with 100% oxygen, and (3) administering an IV general barbiturate or anesthetic medication.

DIF: Application/Applying REF: p. 2197 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Therapeutic Procedures

6. After stabilizing a trauma victims airway, breathing, and circulation, the next item for the ED nurse to assess is

a.

abdomen.

b.

broken bones.

c.

integument.

d.

neurologic status.

ANS: D

Once it is determined that the clients airway, breathing, and circulation (ABC) status is satisfactory, the secondary assessment is performed to identify any other nonlife-threatening problems the client may be experiencing. The secondary assessment includes the following elements: neurologic assessment, history, pain, general overview, and focused assessment.

DIF: Application/Applying REF: pp. 2194, 2195

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

7. A young man is admitted to the ED after sustaining a gunshot wound and dies within a short time. To prepare the body before the familys viewing, the nurse should

a.

remove all clothing in order to give it to the family.

b.

remove all tubes and instruments used in treatment.

c.

wash the body thoroughly.

d.

wrap all clothing already removed and place it in a paper bag.

ANS: D

Tips for preserving evidence in the ED: minimally handle the body of a deceased person; place wet clothing in individual paper bags (do not use plastic bags, as wet clothes can sweat, thereby destroying evidence); and collect the clients personal items. Tubes should not be removed as this client will have an autopsy and they need to be present for that procedure. Washing the body thoroughly may destroy evidence.

DIF: Application/Applying REF: p. 2192 OBJ: Intervention

MSC: Safe, Effective Care Environment Legal Rights and Responsibilities

8. A client is brought to the ED with a suspected neck injury. The nurse should

a.

adjust the table to sit the client upright.

b.

apply a hard cervical collar to the nuchal area.

c.

check for full range of motion of the head.

d.

place a rolled towel under the clients neck.

ANS: B

When there is a suspected neck injury the head should be manually stabilized. Apply a hard cervical collar, place on a spinal board, and place immobilizing devices for the head and neck. The other three options may make a spinal cord injury, if present, worse.

DIF: Application/Applying REF: pp. 2194, 2199

OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Health Alterations

9. A 7-year-old child is brought to the emergency department complaining of arm pain after falling off a swing at school. The child rates the pain as an 8 on a scale of 1-10. The best response by the nurse to this information is to

a.

assume the child is too young to verbalize how much pain he/she is in.

b.

give the child a narcotic pain medication.

c.

obtain further information about the pain using an age-appropriate tool.

d.

send the parents to the waiting room to see if the child gets better without them.

ANS: C

Clients in pain need a thorough pain assessment using the PQRST mnemonic. Children should be assessed using an age-appropriate tool such as the Faces scale. However, any score at 7 or above needs to be considered high risk, evaluated, and then treated appropriately.

DIF: Application/Applying REF: pp. 2195-2196

OBJ: Intervention MSC: Health Promotion Growth and Development

10. A client with a chest injury develops respiratory distress, distended jugular neck veins, and tracheal deviation. The nurse anticipates the client will receive immediate

a.

chest tube insertion.

b.

chest x-ray.

c.

intubation.

d.

needle thoracotomy.

ANS: D

These signs and symptoms are consistent with a tension pneumothorax. The immediate treatment is insertion of a large-bore IV catheter into the anterior chest wall at the second intercostal space, mid-clavicular line. A chest tube may be indicated after emergent treatment, and a chest x-ray will be ordered, but they should not delay the life-saving treatment. Intubation may be needed depending on the clients ability to ventilate and oxygenate post thoracotomy.

DIF: Analysis/Analyzing REF: pp. 2200-2201

OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

11. For children who need crystalloid fluid resuscitation, the formula is altered to

a.

20 ml/kg bolus.

b.

20 ml/kg/hour.

c.

40 ml/kg bolus

d.

40 ml/kg/hour.

ANS: A

Fluid resuscitation in a child is delivered in 20 ml/kg boluses.

DIF: Comprehension/Understanding REF: pp. 2201-2202

OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Parenteral/Intravenous Therapies

12. The nurse is caring for a 100-kg client who sustained a burn injury over 50% of total body surface area (TBSA). How much fluid should this client receive in the first 8 hours?

a.

b.

c.

d.

ANS: C

Fluid resuscitation for burned clients is based on the formula ml/kg/TBSA. The number used for TBSA is the whole number, not the decimal equivalent (i.e., in this case use 50, not 0.5). Half of the volume must be infused within the first 8 hours post-burn.

DIF: Application REF: p. 2202 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Parenteral/Intravenous Therapies

13. A client admitted to the ED exhibits raccoon eyes and Battles sign. The nurse interprets that these manifestations are compatible with

a.

basilar skull fracture.

b.

extreme fatigue and sensory deprivation.

c.

opiate overdose or poisoning.

d.

subarachnoid hemorrhage.

ANS: A

Bruising of the face, eyes (raccoon eyes), or mastoid process (Battles sign) or a bluish hue to the tympanic membrane can indicate a recent head injury and an associated basilar skull fracture.

DIF: Comprehension/Understanding REF: p. 2205 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

14. A nurse is preparing to administer 150 mg of intravenous phenytoin to a client with seizure activity. After diluting the medication with the supplied diluent, the nurse will infuse the medication over a period of

a.

1 minute.

b.

2 minutes.

c.

3 minutes.

d.

4 minutes.

ANS: C

Phenytoin must be diluted and infused at a rate of less than 50 mg/minute.

DIF: Application/Applying REF: p. 2205 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Medication Administration

15. When a client is brought to the ED with chemical injury to the left eye, the nurse would irrigate the eye with normal saline, a minimum of

a.

250 ml.

b.

500 ml.

c.

1000 ml.

d.

2000 ml.

ANS: C

For exposure to harmful chemicals, the eye must be irrigated with a minimum of 1 L of normal saline.

DIF: Application/Applying REF: p. 2206 OBJ: Intervention

MSC: Physiological Integrity Reduction in Risk Potential-Potential for Alterations in Body Systems

16. The nurse is caring for a client brought to the ED after suffering amputation of a toe. The nurse should take care to avoid

a.

cleansing the stump area with normal saline.

b.

placing the toe directly on ice.

c.

placing the wrapped toe in a plastic bag.

d.

wrapping the toe in sterile gauze moistened with saline.

ANS: B

The stump is cleansed with normal saline. The amputated part is wrapped in sterile gauze moistened with normal saline. It is then placed in a plastic bag or container, and the plastic bag or container is placed on ice. The amputated part should never be placed directly on ice because freezing of the tissues will result.

DIF: Application/Applying REF: p. 2208 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Health Alterations

17. The nurse explains to the family of a client with a spinal cord injury that IV methylprednisolone will reduce

a.

pain.

b.

possibility of seizure.

c.

muscle spasms.

d.

spinal cord edema.

ANS: D

Administration of high-dose IV steroids such as methylprednisolone may be considered to reduce cord edema. It has no action on pain, seizures, or muscle spasms.

DIF: Knowledge/Remembering REF: p. 2208 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Expected Effects/Outcomes

18. The nurse clarifies that the law specifies that an ED client cannot be transferred to another facility until the client is stable. Stable is interpreted to mean that the client

a.

has a blood pressure of at least mm Hg.

b.

has been evaluated by a physician.

c.

is conscious and able to provide necessary information.

d.

is not likely to deteriorate during transfer.

ANS: D

Stable means that the clients condition will not deteriorate during the transfer to another facility.

DIF: Comprehension/Understanding REF: p. 2190 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Legal Rights and Responsibilities

19. A teenage girl brings her newborn baby wrapped in a bloody T-shirt into the ED and says she intends to leave the baby there. The nurse should

a.

call the police.

b.

initiate admission to the pediatric unit.

c.

notify social services.

d.

restrain the mother.

ANS: C

People may voluntarily abandon newborns in the care of an ED in many states, which will notify social services, who will take the child into their custody.

DIF: Application REF: p. 2193 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Legal Rights and Responsibilities

MULTIPLE RESPONSE

1. A client has died from very disfiguring injuries received in an automobile accident. When the family arrives moments later, the nurse relays the news to the family and then should (Select all that apply)

a.

allow the family to be alone to grieve.

b.

give information related to the extent of the fatal injuries.

c.

help the family to focus on decisions requiring immediate attention.

d.

tell the family that it is best not to view the body.

ANS: B, C

When death occurs, the ED nurse and physician have important roles in informing the family: provide the family with an explanation of the course of events related to the death; offer the family an opportunity to view the body if desired; help the family focus on decisions requiring immediate attention; and provide community agency referral as needed.

DIF: Application/Applying REF: p. 2193 OBJ: Intervention

MSC: Psychosocial Integrity Grief and Loss

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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