chapter_10 & 12

Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking

for Collaborative Care, 6th Edition

Test Bank

Chapter 10: Concepts of Emergency and Trauma Nursing

Chapter 12: Concepts of Emergency and Disaster Awareness

MULTIPLE CHOICE

1. Which is the most important goal of triage?

A. Assigning each client to the most appropriate treatment area

B. Giving priority of care to the most critically ill or injured clients

C. Providing a through assessment of the client

D. Obtaining a complete history of the client’s past medical-surgical history

ANS: B

The concept of emergency department (ED) triage is based upon sorting clients into

priority levels depending on illness or injury severity. The key concept is that the most

serious clients who present to the ED receive the quickest evaluation and treatment.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A

MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and

Maintenance;

2. What is a correct statement regarding the major role of the triage nurse?

A. Provide a through and comprehensive assessment of each client.

B. Be able to splint and perform minor procedures.

C. Perform rapid assessment to determine priority of care.

D. Provide psychological support to family members.

ANS: C

The triage nurse should perform a rapid assessment to determine triage priority. The

triage nurse should not be assigned tasks or have responsibilities to specific clients that

will draw him or her away from the triage area.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Analysis

MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and

Maintenance;

3. What is the primary survey?

A. Airway, breathing, circulation, head to toe assessment

B. Airway, breathing, circulation, neurologic assessment

C. Airway and cervical spine control, breathing, circulation, disability, exposure

D. Airway and cervical spine control, breathing, circulation, head to toe assessment

ANS: C

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. A, airway and cervical spine

control, B, breathing, C, circulation, D, disability, E, exposure.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: Assessment

MSC: Client Needs Category: Physiological Integrity

4. A 22-year-old male arrives at the ED following a motor vehicle collision. He is not

awake and is being bagged with a bag-valve-mask by paramedics. He has sustained

obvious injuries to his head and face as well as an open right femur fracture that is

bleeding profusely. What should the nurse’s initial intervention be?

A. Splint the right lower extremity to decrease blood loss.

B. Apply direct pressure to the open area on the right leg.

C. Assess for a patent airway.

D. Start two large-bore intravenous lines.

ANS: C

The highest priority intervention in the primary survey is to establish a patent airway.

Without an adequate airway to supply oxygen to the cells, a cerebral injury could

progress to anoxic brain death. After an airway is established, the resuscitation may

continue to B for breathing and C for circulation assessment.

DIF: Cognitive Level: Application or higher

TOP: Nursing Process Step: Assessment


5. What statement best describes the basic concept of mass causality triage?

A. “The greatest good for the greatest amount of people”

B. “First come, first served”

C. “Women and children first”

D. “First priority to the most critical”

ANS: A

Triage for a mass causality incident differs from “civilian” triage in that its main goal is

to provide the most effective care for the greatest number of people. Clients are classified

into one of four categories: emergent, urgent, nonurgent, or expected to die. Clients who

are classified as expected to die would not be assigned first priority in a mass causality

situation.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment

MSC: Client Needs Category: Health Promotion and Maintenance

6. A 67-year-old male presents to the ED complaining of chest pain. His heart rate is

120 beats/min, his blood pressure is 100/68 mm Hg, and his respiratory rate is 20

breaths/min. His is short of breath and diaphoretic. In a three-tiered triage model, how

should the nurse prioritize this client?

A. Emergent

B. Urgent

C. Nonurgent

D. Dormant

ANS: A

In a three-tiered triage model of emergent, urgent, and nonurgent, the client in the

emergent triage category has a condition that may pose an immediate threat to life or

limb and is given the highest priority. The urgent triage category is for clients who should

be treated quickly but who do not have an immediate threat to life if they are not. Clients

categorized as nonurgent generally can tolerate several hours of waiting time without a

significant risk of deterioration.

DIF: Cognitive Level: Application or higher

TOP: Nursing Process Step: Assessment


7. Which of the following statements is true regarding critical incident stress debriefing

(CISD)?

A. CISD should not occur until several months have passed since the incident.

B. CISD consists of a group leader who is the main speaker.

C. CISD encourages group discussion.

D. CISD is limited to health care providers.

ANS: C

CISD is comprised of a team of specially trained individuals who come together quickly

to deal with the emotional needs of health team members who have participated in a

devastating or disturbing incident. Sessions generally last from 1 to 3 hours. CISD group

leaders encourage group discussion by asking a series of questions designed to make

everyone involved explain their part of the story and/or how the incident personally

affected them.

DIF: Cognitive Level: Comprehension

TOP: Nursing Process Step: Implementation/Evaluation

MSC: Client Needs Category: Psychosocial Integrity

8. Which of the following statements are true regarding post-traumatic stress disorder

(PTSD)?

A. Individuals suffering from PTSD may display physical manifestations.

B. Professional “burnout” is rare secondary to PTSD.

C. Critical incident stress management is the only method to deal with PTSD.

D. Manifestations of PTSD are purely psychological.

ANS: A

PTSD may occur in health care providers after an extremely emotional incident. It may

be manifested by multiple psychological and physical effects such as flashbacks,

avoidance, diminished interest in previously enjoyable events, detachment, and physical

manifestations including rapid heart rate and insomnia and other physiologic effects of

anxiety. Individuals suffering from PTSD may have difficulty in relating in their usual

way to family and friends and may ultimately experience professional “burnout.”

DIF: Cognitive Level: Comprehension

TOP: Nursing Process Step: Implementation/Evaluation

MSC: Client Needs Category: Psychosocial Integrity

OTHER

1. Which of the following interventions should be performed during the primary survey

for trauma? (Select all that apply.)

A. Removal of wet clothing

B. Splinting of open fractures

C. Initiating IV fluids

D. Endotracheal intubation

E. Foley catheterization

F. Needle decompression

G. Laceration repair

H. Rectal examination

ANS:

A, C, D, F

Rationale: 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. A, airway and cervical

spine control, B, breathing, C, circulation, D, disability, E, exposure. After completion of

the primary diagnostic studies, laboratory studies, and insertion of gastric and urinary

tubes, the secondary survey, a complete head to toe assessment can be carried out.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment


2. Choose the interventions that are appropriate under the primary survey. (Select all

that apply.)

A. Blood transfusion

B. Insertion of a chest tube

C. Endotracheal intubation

D. Laceration repair

E. Insertion of a nasogastric tube

ANS:

A, B, C

During the primary survey, life-threatening conditions are identified and managed

simultaneously. During the secondary survey, a complete head to toe assessment is

performed to identify and management any nonurgent injuries such as fractures and

lacerations.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step:

Implementation


chapter_10 & 12

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