Test bank for understanding the essentials of critical care nursing 2nd edition by perrin

Link download full: https://getbooksolutions.com/download/test-bank-forpathophysiology-the-biologic-basis-for-disease-in-adults-and-children-6thedition-by-mccance Understanding the Essentials of Critical Care Nursing, 2nd Edition Test Bank – Perrin Understanding the Essentials of Critical Care Nursing, 2nd Edition Test Bank – Perrin Perrin, Understanding the Essentials of Critical Care Nursing, 2/e Chapter Question Type: MCSA A patient arrives in the emergency department with a flail chest after a motor vehicle accident (MVA) in which the patient’s chest hit the steering wheel The nurse realizes this injury is due to: Blunt trauma from internal forces caused by acceleration Blunt trauma from external forces caused by deceleration Penetrating trauma from external forces caused by deceleration Penetrating trauma from internal forces caused by acceleration Correct Answer: Rationale 1: Internal forces refer to stress or strain created within the body, not from outside forces Acceleration forces are when the increasing speed hits someone who is stationary, such as a car hitting a person crossing the street Rationale 2: Blunt trauma leaves the skin intact and damage to underlying tissue, such as broken ribs External forces are created by the mass of the object and velocity of movement outside the body and the weight of the person being pushed forward after the car hit something Deceleration is the force that stops or decreases the velocity of the moving victim, such as the chest hitting the steering wheel Rationale 3: Penetrating wounds have an open wound and flail chests are intact at the skin level Rationale 4: Penetrating wounds have an open wound and flail chests are intact at the skin level Internal forces refer to stress or strain created within the body, not from outside forces Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-1: Compare and contrast blunt and penetrating trauma Question Type: MCSA Which patient sustained an open traumatic injury? A patient with: A closed hip fracture that was caused by a fall A gun shot wound without penetration of the bullet due to the bullet-proof vest Near-drowning after falling through a frozen lake Burns over 30% of the body from a house fire Correct Answer: Rationale 1: This is an example of blunt trauma in which the skin is not broken, but underlying tissue is damaged Rationale 2: This is an example of blunt trauma in which the skin is not broken, but underlying tissue is damaged Rationale 3: This is an example of blunt trauma in which the skin is not broken, but underlying tissue is damaged Rationale 4: Burns over 30% of the body from a house fire is an example of an open or penetrating wound in which the skin does not remain intact Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-1: Compare and contrast blunt and penetrating trauma Question Type: MCMA When performing a quick assessment to identify life-threatening problems in a trauma patient, the nurse would include which assessments under the D–Disability section? Note: Credit will be given only if all correct choices and no incorrect choices are selected Standard Text: Select all that apply Ability to respond to painful stimuli Vital signs Ability to respond to verbal command Level of consciousness or unconsciousness Oxygen saturation levels Correct Answer: 1,3,4 Rationale 1: This is assessed under the disability part of the primary assessment Rationale 2: Vital signs are classified under F–Full set of vital signs Rationale 3: This is assessed under the disability part of the primary assessment Rationale 4: This is assessed under the disability part of the primary assessment Rationale 5: Oxygen levels are covered under C–Circulation of the primary assessment steps Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-2: Describe elements of the primary and secondary assessments Question Type: MCSA What activities would the nurse implement under the A section of assessment priorities when admitting a trauma patient with a suspected spinal cord injury? Using a manual ventilation bag Applying heated blankets Using the jaw thrust maneuver Assessing for history of asthma Correct Answer: Rationale 1: This action would be seen in step B–Breathing Rationale 2: This action would be seen in step E–Environment/exposure Rationale 3: Airway is covered under the A section Maintaining an open airway is the first priority With a fracture or trauma to the neck, respirations may be altered or prevented by bone or tissue misalignment The jaw thrust maneuver is the correct way to open the airway for a cervical spine injury Rationale 4: This action is performed in step H–Head-to-toe assessment/medical history Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-2: Describe elements of the primary and secondary assessments Question Type: MCMA Which risk factors could lead to the development of airway failure if not recognized while assessing the airway of a trauma patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected Standard Text: Select all that apply Chest wall injury Displacement of the trachea (tracheal shift) Aspiration of gastric contents Foreign object occlusion of the throat/mouth Swelling of soft tissue in the throat Correct Answer: 2,3,4,5 Rationale 1: The chest wall injury would be a breathing survey assessment because it focuses on thoracic trauma and the ability to ventilate and not obstruct the airway itself Rationale 2: This can obstruct the airflow into or out of the lungs and cause airway failure Rationale 3: This can obstruct the airflow into or out of the lungs and cause airway failure Rationale 4: This can obstruct the airflow into or out of the lungs and cause airway failure Rationale 5: This can obstruct the airflow into or out of the lungs and cause airway failure Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-4: Discuss airway problems that may develop in a trauma patient Question Type: MCSA Which nursing assessment would have highest priority for early airway management of a trauma patient? Ask the patient to state his name Assess increasing intracranial pressure (ICP) with facial fractures Prepare for emergency tracheostomy Perform a computerized tomography (CT) scan of tissues of the neck Correct Answer: Rationale 1: If the patient can state his name audibly then the airway is patent Rationale 2: ICP monitoring might be needed but it is not the first priority of the nurse for airway issues Rationale 3: Emergency tracheostomy might be needed but it is still a second action only if needed Rationale 4: CT scanning might be needed but it is not the first priority of the nurse for airway issues Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-4: Discuss airway problems that may develop in a trauma patient Question Type: MCSA Which assessment finding indicates that a trauma patient is having problems with breathing rather than difficulty maintaining an airway? Pain with swallowing, coughing, or hemoptysis Chest pain on inspiration Popping sound (crepitus) in the throat when touching the skin by the trachea Hoarseness when talking Correct Answer: Rationale 1: Each of these symptoms is an example of an airway maintenance issue that can contribute to decreased airflow through the throat Rationale 2: Chest pain is a breathing issue and not an airway problem Rationale 3: Crepitus is noted with laryngeal fractures where air is escaping into the subcutaneous tissue Rationale 4: This is an example of an airway maintenance issue that can contribute to decreased airflow through the throat Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-4: Discuss airway problems that may develop in a trauma patient Question Type: MCMA Which will the nurse assess when evaluating breathing in a patient suspected of having a thoracic trauma? Note: Credit will be given only if all correct choices and no incorrect choices are selected Standard Text: Select all that apply Jugular vein distention Symmetry of chest movement bilaterally Chest movements that rise and fall with breathing effort Respiratory rate, pattern, and effort Peripheral skin coloring Correct Answer: 1,2,3,4 Rationale 1: Jugular vein distention will increase when chest pressure rises with displacement or fluid buildup in which the heart must work harder to circulate the blood and perfuse tissues that are hypoxic Rationale 2: Chest movement symmetry will be assessed in the patient with thoracic trauma Rationale 3: Chest movements that rise and fall with breathing will be assessed in the patient with thoracic trauma Rationale 4: Respiratory rate, pattern, and effort will be assessed in the patient with thoracic trauma Rationale 5: Skin coloring is a circulation issue, not a breathing issue Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-5: Compare and contrast manifestations and management of various types of thoracic trauma Question Type: MCSA What will the nurse expect to assess in a patient with a tension pneumothorax? Tracheal deviation to the unaffected side Bilateral equal chest movement Decreased muscular effort by chest muscles Decreasing central venous pressure (CVP) Correct Answer: Rationale 1: As air accumulates on the pleural space with no place to escape, the affected lung collapses and the resulting increase on intrathoracic pressure puts pressure on the trachea, which causes displacement to the unaffected side Rationale 2: Normal breathing is bilaterally equal In a tension pneumothorax, one or more areas of the lung tissue collapses and does not expand, therefore limiting the chest movement on that side Therefore, the movement is bilaterally unequal Rationale 3: Increased muscle effort will be the response to decreasing lung activity Extra muscles of the chest are called into place to try to increase the effort to move the air within the lung tissues Rationale 4: The CVP will increase to try to compensate for decreased pulmonary perfusion from a decrease in the surface area for oxygen to be exchanged Rationale 4: The ECG will show tachycardia from hypovolemia Widening QRS show slowed conduction in the ventricles and would not be a sign of abdominal distress Rationale 5: Widening pulse pressure is not seen in the patient with traumatic abdominal injury Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9-9: Describe elements of an abdominal assessment of the patient with a traumatic injury Identify when surgery may be required Question 21 Type: MCSA Under what circumstance would the nurse expect to prepare a patient for surgery when abdominal trauma has occurred? A patient with: A suspected splenic injury and who has received unit of blood A Grade III liver injury with stable vital signs A contusion to the kidney with a stable H & H A pelvic fracture with muscle rigidity of the abdominal wall Correct Answer: Rationale 1: If additional bleeding requires more than units of blood or becomes unstable, the patient with splenic injury will require surgical repair to stop the bleeding Rationale 2: In a Grade III liver injury, conservative management outweighs the risks of surgery If a Grade IV or V injury occurs in the liver, then surgical repair is called for immediately Rationale 3: With a contusion to the kidney bedrest and careful assessment of renal status is enough for the contusion to resolve with time Rationale 4: The patient with a pelvic fracture is exhibiting signs of bladder rupture by the muscle rigidity Immediate surgery is required to assess and repair the damage to internal organs Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9-9: Describe elements of an abdominal assessment of the patient with a traumatic injury Identify when surgery may be required Question 22 Type: MCSA Under the F section of the assessment process, in addition to full vital signs, the family is considered as a part of the treatment process Which approach to the family would be most appropriate for the nurse to use? The family gets in the way of acute care management so the nurse should offer no support until the patient is stable Ethically the family has a right to support the patient by being at the bedside during acute care management, including trauma resuscitation Depending on the family’s awareness of health care management, they have the privilege to watch the care if they not get in the way of the care Because the care during trauma management can be too graphic for family to witness, the family should not be allowed at the bedside Correct Answer: Rationale 1: This is a bias and it has been shown that having family at the bedside to support the patient will frequently give a better outcome Rationale 2: Legally and ethically the family has the right to be with the patient under all circumstances, including trauma resuscitation This topic is greatly debated but the right is still present and often left to the physician to decide if the family should step out Rationale 3: With or without the medical/health care background, the right is still present and it is not a privilege to be awarded by staff Rationale 4: Even if the circumstance is graphic for the family, the right is present and benefits will be gained by the patient The focus of care is not the family’s needs first but the patient’s Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-10: Analyze the benefits of family presence during trauma resuscitation and care Question 23 Type: MCMA What can the nurse to convey comfort to a trauma patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected Standard Text: Select all that apply Explain and talk to the patient, not ignore the patient Give clear precise directions to follow Directly look at the eyes of the patient when talking Human contact such as a reassuring touch Giving all details to get full cooperation Correct Answer: 1,2,3,4 Rationale 1: This will convey comfort to a trauma patient Rationale 2: This will convey comfort to a trauma patient Rationale 3: This will convey comfort to a trauma patient Rationale 4: This will convey comfort to a trauma patient Rationale 5: Giving extensive details will delay care and often confuses the patient in a traumatic situation and increases the patient’s anxiety rather than reducing stress A patient under stress can best comprehend and follow brief directions given in a comforting manner to allow the staff to their job without having to over explain or rationalize why they are doing what they are doing during the “golden” hour that may mean the difference between life and death Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort Nursing/Integrated Concepts: Caring Learning Outcome: 9-11: Discuss ways a nurse might provide comfort to the trauma patient Question 24 Type: MCMA The nurse would include which activities when planning care to increase comfort for the intubated patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected Standard Text: Select all that apply Speak directly to the patient by looking into the patient’s eyes Keep the patient sedated and let the patient sleep when giving care Give additional pain medication whenever restlessness is noted Establish a communication method that does not require talking Keep the family at the bedside to interpret the patient’s needs Correct Answer: 1,4 Rationale 1: Developing eye contact will give comfort and reassurance when the patient is unable to speak while intubated Rationale 2: Sedation and not talking to the patient not give support to the patient Sedation may be needed but explaining the reason and timing for such should be for the improved ventilatory effectiveness and not the nurse’s convenience Rationale 3: Pain medication needs to be given based on the patient’s interpretation of its need Restlessness is often a symptom of hypoxia and further assessment needs to be done before just medicating the patient Rationale 4: Developing a separate method of communication such as blinking one’s eyes or squeezing the nurse’s hand will give comfort and reassurance when the patient is unable to speak while intubated Rationale 5: It is not the family’s role to communicate or to meet the needs of the patient It is a nursing obligation to identify and meet the needs of the patient Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9-11: Discuss ways a nurse might provide comfort to the trauma patient Question 25 Type: MCMA The nurse is planning interventions for a trauma patient to prevent the onset of the lethal triad What will the nurse include in this patient’s plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected Standard Text: Select all that apply Monitor temperature Measure intake and output Evaluate laboratory data Assess arterial blood gas values Measure gastric pH Correct Answer: 1,2,3,4 Rationale 1: Monitoring body temperature is critical in the prevention of deaths from the lethal triad Rationale 2: Measuring intake and output is critical in the prevention of deaths from the lethal triad Rationale 3: Evaluating recent laboratory data is critical in the prevention of deaths from the lethal triad Rationale 4: Assessing arterial blood gas values is critical in the prevention of deaths from the lethal triad Rationale 5: Measuring gastric pH is not critical in the prevention of deaths from the lethal triad Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9-3: Explain the “lethal triad” of trauma mortality Question 26 Type: MCMA The nurse is preparing to complete the secondary survey of a patient admitted with a traumatic chest injury On what will the nurse focus when conducting this survey? Note: Credit will be given only if all correct choices and no incorrect choices are selected Standard Text: Select all that apply Full set of vital signs Comfort measures Head-to-toe assessment Assessment of posterior surfaces Exposure Correct Answer: 1,2,3,4 Rationale 1: This is a part of the secondary trauma survey Rationale 2: This is a part of the secondary trauma survey Rationale 3: This is a part of the secondary trauma survey Rationale 4: This is a part of the secondary trauma survey Rationale 5: This is a part of the primary trauma survey Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-2: Describe elements of the primary and secondary assessments Question 27 Type: MCMA The nurse is concerned that a patient receiving emergency care for maxillofacial injuries from a motor vehicle crash sustained laryngeal trauma because of which assessment findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected Standard Text: Select all that apply Hoarse speech Pain when swallowing Coughing blood Epistaxis Periorbital edema Correct Answer: 1,2,3 Rationale 1: The patient with laryngeal trauma will demonstrate hoarse speech Rationale 2: Painful swallowing is a manifestation of laryngeal trauma Rationale 3: Hemoptysis is a manifestation of laryngeal trauma Rationale 4: Epistaxis is not a manifestation of laryngeal trauma but would be present because of the maxillofacial trauma Rationale 5: Periorbital edema is not a manifestation of laryngeal trauma but would be present because of the maxillofacial trauma Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-4: Discuss airway problems that may develop in a trauma patient Question 28 Type: MCMA The nurse assesses a patient with a penetrating abdominal wound as a Class IV hemorrhage because of which findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected Standard Text: Select all that apply Heart rate 160 Respiratory rate 28 Mean arterial pressure 50 Capillary refill seconds Mild decrease in urine output Correct Answer: 1,2,3,4 Rationale 1: Heart rate greater than 140 is an indication of Class IV hemorrhage Rationale 2: Tachypnea is an indication of Class IV hemorrhage Rationale 3: Mean arterial pressure less than 60 is an indication of Class IV hemorrhage Rationale 4: Delayed capillary refill is an indication of Class IV hemorrhage Rationale 5: Mild decrease in urine output would be seen in a Class II hemorrhage Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-6: Recognize the manifestations of hemorrhagic shock and plan management strategies Question 29 Type: MCMA While caring for a patient with thoracic injuries from a motor vehicle crash, the nurse suspects the patient is developing cardiac tamponade because of which assessment findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected Standard Text: Select all that apply Dropping blood pressure Jugular vein distention Muffled heart sounds Drop in blood pressure on inspiration Increase in blood pressure on inspiration Correct Answer: 1,2,3,4 Rationale 1: Hypotension is an assessment finding within Beck’s triad indicating cardiac tamponade Rationale 2: An increase in central venous pressure assessed as jugular vein distention is an assessment finding within Beck’s triad indicating cardiac tamponade Rationale 3: Heart sounds are muffled in cardiac tamponade because of the accumulation of fluid in the pericardial sac This is an assessment finding within Beck’s triad indicating cardiac tamponade Rationale 4: In paradoxical pulse, blood pressure is at least 10 mm Hg higher on expiration than on inspiration This is an assessment finding of cardiac tamponade Rationale 5: In cardiac tamponade, the blood pressure is higher on expiration than inspiration Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-7: Explain cardiac tamponade Question 30 Type: MCMA A patient is admitted with injuries sustained from a skiing accident While completing the primary survey, the nurse suspects the patient has an injury to the spleen because of which findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected Standard Text: Select all that apply Heart rate 120 Referred pain to the left shoulder Upper left quadrant abdominal pain Hematuria Flank ecchymosis Correct Answer: 1,2,3 Rationale 1: A rapid heart rate can indicate hemorrhage or hypovolemic shock which is an assessment finding consistent with an injury to the spleen Rationale 2: Kehr’s sign is referred pain to the left shoulder This is an assessment finding consistent with an injury to the spleen Rationale 3: Upper left quadrant abdominal tenderness or pain is an assessment finding consistent with an injury to the spleen Rationale 4: Hematuria is not an assessment finding consistent with an injury to the spleen Rationale 5: Bruising or ecchymosis over the flank area is not an assessment finding consistent with an injury to the spleen Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-9: Describe elements of an abdominal assessment of the patient with a traumatic injury Identify when surgery may be required Question 31 Type: MCMA A patient with massive injuries to the head and chest has died The family is in the hallway waiting to see the patient What can the nurse to prepare the family to be with the patient at this time? Note: Credit will be given only if all correct choices and no incorrect choices are selected Standard Text: Select all that apply Remove blood soaked bed sheets and gown Have at least one of the patient’s hands readily available for the family to touch Place the stretcher in the low position Turn one dim light on in the room Leave the family to visit with the patient Correct Answer: 1,2,3,4 Rationale 1: The nurse should remove body fluids from the environment Rationale 2: The nurse should make sure the patient’s hand is out and secured Rationale 3: The nurse should make sure the stretcher is in the low position so that chairs can be placed around it Rationale 4: Turning on one dim light in the room calms the room Rationale 5: The nurse should be present to answer questions and provide support Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Caring Learning Outcome: 9-10: Analyze the benefits of family presence during trauma resuscitation and care Question 32 Type: MCMA A patient with traumatic injuries to the abdomen expresses the fear of dying What can the nurse to provide comfort to the patient at this time? Note: Credit will be given only if all correct choices and no incorrect choices are selected Standard Text: Select all that apply Face the patient when talking State phrases that demonstrate care and comfort Hold the patient’s hand Provide pain medication Leave the patient to rest Correct Answer: 1,2,3 Rationale 1: Using the en face position is comforting to a patient with traumatic injuries Rationale 2: Using comfort talk is helpful to the patient with traumatic injuries Rationale 3: Providing physical contact by holding the patient’s hand provides comfort to the patient with traumatic injuries Rationale 4: The use of pain medication is not identified as an intervention to provide comfort to the patient with traumatic injuries Rationale 5: Leaving the patient alone is not identified as an intervention of comfort to the patient with traumatic injuries