Chapter 08 Concepts of Emergency and Trauma Nursing PDF

Preview

Summary

Download Chapter 08 Concepts of Emergency and Trauma Nursing PDF

Description

TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

50

Chapter08:ConceptsofEmergencyandTraumaNursing MULTIPLECHOICE 1.Anemergencyroomnurseassessesaclientwhohasbeenraped.Withwhichhealthcareteammember shouldthenursecollaboratewhenplanningthisclientscare? a.Emergencymedicinephysician b.Casemanager c.Forensicnurseexaminer d.Psychiatriccrisisnurse ANS:C Allothermembersofthehealthcareteamlistedmaybeusedinthemanagementofthisclientscare.However, theforensicnurseexamineriseducatedtoobtainclienthistoriesandcollectevidencedealingwiththeassault, andcanofferthecounselingandfollow-upneededwhendealingwiththevictimofanassault. DIF:Understanding/ComprehensionREF:118 KEY:Interdisciplinaryteam|emergencynursing MSC:IntegratedProcess:NursingProcess:Planning NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 2.Theemergencydepartmentteamisperformingcardiopulmonaryresuscitationonaclientwhentheclients spousearrivesattheemergencydepartment.Whichactionshouldthenursetakefirst? a.Requestthattheclientsspousesitinthewaitingroom. b.Askthespouseifhewishestobepresentduringtheresuscitation. c.Suggestthatthespousebegintoprayfortheclient. d.Refertheclientsspousetothehospitalscrisisteam. ANS:B Ifresuscitationeffortsarestillunderwaywhenthefamilyarrives,oneortwofamilymembersmaybegiven theopportunitytobepresentduringlifesavingprocedures.Theotheroptionsdonotgivethespousethe opportunitytobepresentfortheclientortobegintohaveclosure. DIF:Applying/ApplicationREF:126 KEY:Death|emergencynursingMSC:IntegratedProcess:Caring NOT:ClientNeedsCategory:PsychosocialIntegrity 3.Anemergencyroomnurseistriagingvictimsofamulti-casualtyevent.Whichclientshouldreceivecare first? a.A30-year-olddistraughtmotherholdinghercryingchild b.A65-year-oldconsciousmalewithaheadlaceration c.A26-year-oldmalewhohaspale,cool,clammyskin d.A48-year-oldwithasimplefractureofthelowerleg ANS:C Theclientwithpale,cool,clammyskinisinshockandneedsimmediatemedicalattention.Themotherdoes nothaveinjuriesandsowouldbethelowestpriority.Theothertwopeopleneedmedicalattentionsoon,but notattheexpenseofapersoninshock. DIF:Applying/ApplicationREF:129 KEY:Triage|emergencynursing MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 4.Whiletriagingclientsinacrowdedemergencydepartment,anurseassessesaclientwhopresentswith symptomsoftuberculosis.Whichactionshouldthenursetakefirst? a.Applyoxygenvianasalcannula. b.Administerintravenous0.9%salinesolution. c.Transfertheclienttoanegative-pressureroom.

TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

51

d.Obtainasputumcultureandsensitivity. ANS:C Aclientwithsignsandsymptomsoftuberculosisorotherairbornepathogensshouldbeplacedinanegativepressureroomtopreventcontaminationofstaff,clients,andfamilymembersinthecrowdedemergency department. DIF:Applying/ApplicationREF:120 KEY:Infectioncontrol|Transmission-BasedPrecautions|emergencynursing|staffsafety MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:SafetyandInfectionControl 5.Anurseistriagingclientsintheemergencydepartment(ED).Whichclientshouldthenurseprioritizeto receivecarefirst? a.A22-year-oldwithapainfulandswollenrightwrist b.A45-year-oldreportingchestpainanddiaphoresis c.A60-year-oldreportingdifficultyswallowingandnausea d.An81-year-oldwitharespiratoryrateof28breaths/minandatemperatureof101F ANS:B Aclientexperiencingchestpainanddiaphoresiswouldbeclassifiedasemergentandwouldbetriaged immediatelytoatreatmentroomintheED.Theotherclientsaremorestable. DIF:Applying/ApplicationREF:123 KEY:Triage|emergencynursing MSC:IntegratedProcess:NursingProcess:Planning NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 6.Anurseisevaluatinglevelsandfunctionsoftraumacenters.Whichfunctionisappropriatelypairedwiththe levelofthetraumacenter? a.LevelILocatedwithinremoteareasandprovidesadvancedlifesupportwithinresourcecapabilities b.LevelIILocatedwithincommunityhospitalsandprovidescaretomostinjuredclients c.LevelIIILocatedinruralcommunitiesandprovidesonlybasiccaretoclients d.LevelIVLocatedinlargeteachinghospitalsandprovidesafullcontinuumoftraumacareforallclients ANS:B LevelItraumacentersareusuallylocatedinlargeteachinghospitalsystemsandprovideafullcontinuumof traumacareforallclients.BothLevelIIandLevelIIIfacilitiesareusuallylocatedincommunityhospitals. ThesetraumacentersprovidecareformostclientsandtransporttoLevelIcenterswhenclientneedsexceed resourcecapabilities.LevelIVtraumacentersareusuallylocatedinruralandremoteareas.Thesecenters providebasiccare,stabilization,andadvancedlifesupportwhiletransferarrangementstohigher-leveltrauma centersaremade. DIF:Remembering/KnowledgeREF:127 KEY:Traumacenter|emergencynursing MSC:IntegratedProcess:NursingProcess:Planning NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 7.Emergencymedicaltechniciansarriveattheemergencydepartmentwithanunresponsiveclientwhohasan oxygenmaskinplace.Whichactionshouldthenursetakefirst? a.Assessthattheclientisbreathingadequately. b.Insertalarge-boreintravenousline. c.Placetheclientonacardiacmonitor. d.Assessforthebestneurologicresponse. ANS:A Thehighest-priorityinterventionintheprimarysurveyistoestablishthattheclientisbreathingadequately. Eventhoughthisclienthasanoxygenmaskon,heorshemaynotbebreathing,ormaybebreathing inadequatelywiththedeviceinplace.

TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

52

DIF:Applying/ApplicationREF:128 KEY:Primarysurvey|emergencynursing MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 8.Atraumaclientwithmultipleopenwoundsisbroughttotheemergencydepartmentincardiacarrest.Which actionshouldthenursetakepriortoprovidingadvancedcardiaclifesupport? a.Contacttheon-callorthopedicsurgeon. b.Donpersonalprotectiveequipment. c.NotifytheRapidResponseTeam. d.Obtainacompletehistoryfromtheparamedic. ANS:B Nursesmustrecognizeandplanforahighriskofcontaminationwithbloodandbodyfluidswhenengagingin traumaresuscitation.StandardPrecautionsshouldbetakeninallresuscitationsituationsandatothertimes whenexposuretobloodandbodyfluidsislikely.Properattireconsistsofanimperviouscovergown,gloves, eyeprotection,afacemask,asurgicalcap,andshoecovers. DIF:Applying/ApplicationREF:128 KEY:Infectioncontrol|StandardPrecautions|emergencynursing|staffsafety MSC:IntegratedProcess:NursingProcess:Planning NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:SafetyandInfectionControl 9.Anurseistriagingclientsintheemergencydepartment.Whichclientshouldbeconsideredurgent? a.A20-year-oldfemalewithacheststabwoundandtachycardia b.A45-year-oldhomelessmanwithaskinrashandsorethroat c.A75-year-oldfemalewithacoughandatemperatureof102F d.A50-year-oldmalewithnew-onsetconfusionandslurredspeech ANS:C Aclientwithacoughandatemperatureof102Fisurgent.Thisclientisatriskfordeteriorationandneedsto beseenquickly,butisnotinanimmediatelylife-threateningsituation.Theclientwithacheststabwoundand tachycardiaandtheclientwithnew-onsetconfusionandslurredspeechshouldbetriagedasemergent.The clientwithaskinrashandasorethroatisnotatriskfordeteriorationandwouldbetriagedasnonurgent. DIF:Applying/ApplicationREF:124 KEY:Triage|emergencynursing MSC:IntegratedProcess:NursingProcess:Planning NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 10.Anemergencydepartmentnurseiscaringforaclientwhohasdiedfromasuspectedhomicide.Which actionshouldthenursetake? a.Removealltubesandwiresinpreparationforthemedicalexaminer. b.Limitthenumberofvisitorstominimizethefamilystrauma. c.Consultthebereavementcommitteetofollowupwiththegrievingfamily. d.Communicatetheclientsdeathtothefamilyinasimpleandconcretemanner. ANS:D Whendealingwithclientsandfamiliesincrisis,communicateinasimpleandconcretemannertominimize confusion.Tubesmustremaininplaceforthemedicalexaminer.Familyshouldbeallowedtoviewthebody. Offeringtocallforadditionalfamilysupportduringthecrisisissuggested.Thebereavementcommitteeshould beconsulted,butthisisnotthepriorityatthistime. DIF:Applying/ApplicationREF:126 KEY:Death|emergencynursingMSC:IntegratedProcess:Caring NOT:ClientNeedsCategory:PsychosocialIntegrity 11.Anemergencydepartment(ED)casemanagerisconsultedforaclientwhoishomeless.Which interventionshouldthecasemanagerprovide?

TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

53

a.Communicateclientneedsandrestrictionstosupportstaff. b.Prescribelow-costantibioticstotreatcommunity-acquiredinfection. c.Providereferralstosubsidizedcommunity-basedhealthclinics. d.Offercounselingforsubstanceabuseandmentalhealthdisorders. ANS:C Casemanagementinterventionsincludefacilitatingreferralstoprimarycareproviderswhoareacceptingnew clientsortosubsidizedcommunity-basedhealthclinicsforclientsorfamiliesinneedofroutineservices.The EDnurseisaccountableforcommunicatingpertinentstaffconsiderations,clientneeds,andrestrictionsto supportstaff(e.g.,physicallimitations,isolationprecautions)toensurethatongoingclientandstaffsafety issuesareaddressed.TheEDphysicianprescribesmedicationsandtreatments.Thepsychiatricnurseteam evaluatesclientswithemotionalbehaviorsormentalillnessandfacilitatesthefollow-uptreatmentplan, includingpossibleadmissiontoanappropriatepsychiatricfacility. DIF:Understanding/ComprehensionREF:126 KEY:Interdisciplinaryteam|emergencynursing MSC:IntegratedProcess:NursingProcess:Planning NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 12.Anemergencydepartmentnurseiscaringforaclientwhoishomeless.Whichactionshouldthenursetake togaintheclientstrust? a.Speakinaquietandmonotonevoice. b.Avoideyecontactwiththeclient. c.Listentotheclientsconcernsandneeds. d.Asksecuritytostoretheclientsbelongings. ANS:C Todemonstratebehaviorsthatpromotetrustwithhomelessclients,theemergencyroomnurseshouldmake eyecontact(ifculturallyappropriate),speakcalmly,avoidanyprejudicialorstereotypicalremarks,show genuinecareandconcernbylistening,andfollowthroughonpromises.Thenurseshouldalsorespectthe clientsbelongingsandpersonalspace. DIF:Understanding/ComprehensionREF:126 KEY:Interdisciplinaryteam|emergencynursing|casemanagement MSC:IntegratedProcess:NursingProcess:Planning NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 13.Anurseistriagingclientsintheemergencydepartment.Whichclientshouldthenurseclassifyas nonurgent? a.A44-year-oldwithchestpainanddiaphoresis b.A50-year-oldwithchesttraumaandabsentbreathsounds c.A62-year-oldwithasimplefractureoftheleftarm d.A79-year-oldwithatemperatureof104F ANS:C Aclientinanonurgentcategorycantoleratewaitingseveralhoursforhealthcareserviceswithoutasignifican riskofclinicaldeterioration.Theclientwithasimplearmfractureandpalpableradialpulsesiscurrently stable,isnotatsignificantriskofclinicaldeterioration,andwouldbeconsiderednonurgent.Theclientwith chestpainanddiaphoresisandtheclientwithchesttraumaareemergentowingtothepotentialforclinical deteriorationandwouldbeseenimmediately.Theclientwithahighfevermaybestablenowbutalsohasa riskofdeterioration. DIF:Applying/ApplicationREF:123 KEY:Triage|emergencynursing MSC:IntegratedProcess:NursingProcess:Planning NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare MULTIPLERESPONSE

TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

54

1.Anurseiscaringforclientsinabusyemergencydepartment.Whichactionsshouldthenursetaketoensure clientandstaffsafety?(Selectallthatapply.) a.Leavethestretcherinthelowestpositionwithrailsdownsothattheclientcanaccessthebathroom. b.Usetwoidentifiersbeforeeachinterventionandbeforemediationadministration. c.Attemptde-escalationstrategiesforclientswhodemonstrateaggressivebehaviors. d.Searchthebelongingsofclientswithalteredmentalstatustogainessentialmedicalinformation. e.Isolateclientswhohaveimmunesuppressiondisorderstopreventhospital-acquiredinfections. ANS:B,C,D Toensureclientandstaffsafety,nursesshouldusetwoidentifiersperTheJointCommissionsNationalPatient SafetyGoals;followthehospitalssecurityplan,includingde-escalationstrategiesforpeoplewhodemonstrate aggressiveorviolenttendencies;andsearchbelongingstoidentifyessentialmedicalinformation.Nurses shouldalsousestandardfallpreventioninterventions,includingleavingstretchersinthelowestpositionwith railsup,andisolatingclientswhopresentwithsignsandsymptomsofcontagiousinfectiousdisorders. DIF:Applying/ApplicationREF:120 KEY:Safety|patientsafety|staffsafety MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:SafetyandInfectionControl 2.Anemergencydepartment(ED)nurseispreparingtotransferaclienttothetraumaintensivecareunit. Whichinformationshouldthenurseincludeinthenurse-to-nursehand-offreport?(Selectallthatapply.) a.Mechanismofinjury b.Diagnostictestresults c.Immunizations d.Listofhomemedications e.Isolationprecautions ANS:A,B,E Hand-offcommunicationshouldbecomprehensivesothatthereceivingnursecancontinuecarefortheclient fluidly.Communicationshouldbeconciseandshouldincludeonlythemostessentialinformationforasafe transitionincare.Hand-offcommunicationshouldincludetheclientssituation(reasonforbeingintheED), briefmedicalhistory,assessmentanddiagnosticfindings,Transmission-BasedPrecautionsneeded, interventionsprovided,andresponsetothoseinterventions. DIF:Applying/ApplicationREF:120 KEY:SBAR|hand-offcommunication MSC:IntegratedProcess:CommunicationandDocumentation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 3.Anemergencyroomnurseiscaringforatraumaclient.Whichinterventionsshouldthenurseperform duringtheprimarysurvey?(Selectallthatapply.) a.Foleycatheterization b.Needledecompression c.InitiatingIVfluids d.Splintingopenfractures e.Endotrachealintubation f.Removingwetclothing g.Lacerationrepair ANS:B,C,E,F Theprimarysurveyforatraumaclientorganizestheapproachtotheclientsothatlife-threateninginjuriesare rapidlyidentifiedandmanaged.TheprimarysurveyisbasedonthestandardmnemonicABC,withanaddedD andE:Airwayandcervicalspinecontrol;Breathing;Circulation;Disability;andExposure.Afterthe completionofprimarydiagnosticandlaboratorystudies,andtheinsertionofgastricandurinarytubes,the secondarysurvey(acompletehead-to-toeassessment)canbecarriedout. DIF:Applying/ApplicationREF:127 KEY:Primarysurvey|emergencynursing

TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

55

MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation 4.Thecomplexcareprovidedduringanemergencyrequiresinterdisciplinarycollaboration.Which interdisciplinaryteammembersarepairedwiththecorrectresponsibilities?(Selectallthatapply.) a.PsychiatriccrisisnurseInteractswithclientsandfamilieswhensuddenillness,seriousinjury,ordeathofa lovedonemaycauseacrisis b.ForensicnurseexaminerPerformsrapidassessmentstoensureclientswiththehighestacuityreceivethe quickestevaluation,treatment,andprioritizationofresources c.TriagenurseProvidesbasiclifesupportinterventionssuchasoxygen,basicwoundcare,splinting,spinal immobilization,andmonitoringofvitalsigns d.EmergencymedicaltechnicianObtainsclienthistories,collectsevidence,andofferscounselingandfollowupcareforvictimsofrape,childabuse,anddomesticviolence e.ParamedicProvidesprehospitaladvancedlifesupport,includingcardiacmonitoring,advancedairway management,andmedicationadministration ANS:A,E Thepsychiatriccrisisnurseevaluatesclientswithemotionalbehaviorsormentalillnessandfacilitatesfollowuptreatmentplans.Thepsychiatriccrisisnursealsoworkswithclientsandfamilieswhenexperiencingacrisis Paramedicsareadvancedlifesupportproviderswhocanperformadvancedtechniquesthatmayinclude cardiacmonitoring,advancedairwaymanagementandintubation,establishingIVaccess,andadministering drugsenroutetotheemergencydepartment.Theforensicnurseexamineristrainedtorecognizeevidenceof abuseandtointerveneontheclientsbehalf.Theforensicnurseexaminerwillobtainclienthistories,collect evidence,andoffercounselingandfollow-upcareforvictimsofrape,childabuse,anddomesticviolence.The triagenurseperformsrapidassessmentstoensureclientswiththehighestacuityreceivethequickest evaluation,treatment,andprioritizationofresources.Theemergencymedicaltechnicianisusuallythefirst caregiverandprovidesbasiclifesupportandtransportationtotheemergencydepartment. DIF:Understanding/ComprehensionREF:118 KEY:Interdisciplinaryteam|emergencynursing MSC:IntegratedProcess:NursingProcess:Planning NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 5.Anursepreparestodischargeanolderadultclienthomefromtheemergencydepartment(ED).Which actionsshouldthenursetaketopreventfutureEDvisits?(Selectallthatapply.) a.Providemedicalsuppliestothefamily. b.Consultahomehealthagency. c.Encourageparticipationincommunityactivities. d.Screenfordepressionandsuicide. e.Completeafunctionalassessment. ANS:D,E Duetothehighrateofsuicideamongolderadults,anurseshouldassessallolderadultsfordepressionand suicide.Thenurseshouldalsoscreenolderadultsforfunctionalassessment,cognitiveassessment,andriskfor fallstopreventfutureEDvisits. DIF:Understanding/ComprehensionREF:124 KEY:Dischargeplanning|olderadult MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:HealthPromotionandMaintenance...