Chapter 26: Emergency or Life-Threatening Situations

Multiple Choice

1. During initial ABCDE assessments of life-threatening conditions, D (disability) in neurologic stat s is assessed b the patient s: a. pupil size. b. degree of responsiveness. c. nuchal rigidity. d. mood and affect.

ANS: B

The D (disability) in neurologic status of the primary assessment is assessed by determination of the patient s degree of responsi eness to stim li.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Basic Care and Comfort

2. You have gone by ambulance to a construction site where an adult male is lying o n the street. The only information you have is that he fell three stories. His neck is immobilized with sacks of concrete mix on either side. Your first action should be to determine: a. airway patency. b. bleeding sites. c. cranial nerve function. d. limb position.

ANS: A

On arriving at the site, the patency of the upper airway is the priority and should be managed before proceeding with further assessments.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Basic Care and Comfort

3. The ABCs of a primary survey would be interrupted to: a. complete the assessment record. b. manage life-threatening conditions. c. reassess the patient s temperat re. d. transport the patient via airlift.

ANS: B

The primary assessment is interrupted to manage a life-threatening condition as soon as it is detected. Once the condition is stabilized, the primary assessment is continued. Recording of events as they occur should be completed in a manner that does not interrupt continued care or transport. Reassessment of the patient s temperat re is inappropriate because it would interrupt the continued assessment process. Transporting the patient may begin after the primary assessment has been completed to determine the needs of the patient adequately.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process implementing MSC: Safe and Effective Care: Management of Care

4. The term status epilepticus is defined as: a. convulsive activity uncontrolled by medication. b. nonconvulsive brain wave disturbance, with psychomotor dysfunction. c. prolonged seizures that occur without recovery of consciousness. d. seizures that result in hypotension, pallor, and prolonged diaphoresis.

ANS: C

Status epilepticus is a prolonged seizure or series of seizures that occur without recovery of consciousness.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Basic Care and Comfort

5. Pulsus paradoxus greater than 20 mm Hg, tachycardia greater than 130 beats/min, and increasing dyspnea are signs of: a. intracranial pressure. b. pulmonary hypertension. c. status asthmaticus. d. tetanic contractions.

ANS: C

Status asthmaticus is a severe and prolonged asthma attack that resists the usual therapeutic approaches. The patient experiences dyspnea, can only get out a few words between breaths, and has tachycardia often greater than 130 beats/min and pulsus paradoxus greater than 20 mm Hg. Pulsus paradoxus is more likely in pericardial effusion, constrictive pericarditis, and severe asthma.

DIF: Cognitive Level: Analyzing (Analysis) OBJ: Nursing process diagnosis

MSC: Physiologic Integrity: Basic Care and Comfort

6. The Cushing triad includes: a. tachycardia. b. irregular respirations. c. tachypnea. d. constricted pupils.

ANS: B

The Cushing triad is associated with increased intracranial pressure. It includes bradycardia, hypertension, and irregular respirations, even Cheyne-Stokes respirations.

DIF: Cognitive Level: Remembering (Knowledge) OBJ: Nursing process diagnosis

MSC: Physiologic Integrity: Basic Care and Comfort

7. Blood, vomitus, and foreign bodies are removed from the oropharynx of the unconscious patient by: a. stimulating the cough reflex. b. using a sweeping motion with the finger. c. performing a back thrust. d. using suction.

ANS: D

Suction is used to remove blood, vomitus, or foreign bodies from the airway of an unconscious patient. The other choices put the patient at risk for aspiration or further injury if a neck injury is involved.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process implementing MSC: Safe and Effective Care: Management of Care

8. While performing the primary survey on a trauma victim, the patient is answering your questions. You may assume that during the time of the questioning: a. his airway is open. b. he is alert and oriented. c. no head injury has occurred. d. there is no respiratory compromise.

ANS: A

The patency of the upper airway is assessed at the start by asking the patient a question. If the patient answers, this is a sign that the airway is open at this time.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Basic Care and Comfort

9. If trauma above the clavicle is suspected, it is important to: a. test range of motion of the neck. b. remove any headgear. c. arrange for neck extension x-ray studies. d. stabilize the neck in a neutral position.

ANS: D

If trauma above the clavicle is suspected, it is necessary to control the cervical spine by stabilizing the neck in a neutral position. Excessive movement can convert a fracture or dislocation without neurologic damage to one with neurologic damage.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Basic Care and Comfort

10. Paradoxical chest movement suggests a: a. spontaneous pneumothorax. b. flail chest. c. clavicle fracture. d. pulmonary contusion.

ANS: B

Paradoxical chest movement is associated with fractured ribs or a flail chest. This fracture should be stabilized immediately.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Basic Care and Comfort

11. Respiratory distress may be evidenced by: a. retractions of accessory muscles. b. bradycardia. c. flushed skin. d. decreased capillary refill time.

ANS: A

Respiratory distress results in an increased intrathoracic negative pressure as the body attempts to suck in more atmospheric air. This increased negative pressure causes the chest wall skin to retract around the ribs during inspiration. The other choices are related to cardiovascular distress.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Basic Care and Comfort

12. On palpating the chest wall of a trauma patient, you feel subcutaneous crepitus (emphysema), which is a sign that: a. air has leaked into soft tissue. b. a fracture underlies the injury. c. a foreign body is present. d. there is vascular obstruction.

ANS: A

Crepitus is a sign of air leakage into soft tissue. Crepitus in soft tissues is caused by air that has penetrated the area as a result of injury; it is also referred to as subcutaneous emphysema. Bony crepitus is a grating or grinding sensation caused by fractured bone ends or joints r bbing together. A foreign bod co ld obstr ct the patient s air a , prod cing stridor, or a bark may be heard with an obstructed airway.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Basic Care and Comfort

13. Clear or amber drainage from the nose or ears of a blunt trauma patient may indicate: a. epiglottitis. b. a retropharyngeal abscess. c. a basilar skull fracture. d. a perforated tympanic membrane.

ANS: C

Clear or amber drainage from the nose or ears may indicate a basilar skull fract ure. Bloody drainage is associated with a perforated tympanic membrane.

DIF: Cognitive Level: Applying (Application)

MSC: Physiologic Integrity: Basic Care and Comfort

14. Delayed capillary refill may alert you to: a. hypovolemic shock. b. moderate hypoxemia. c. subnormal intracranial pressure. d. upper respiratory infection.

ANS: A

OBJ: Nursing process diagnosis

Delayed capillary refill means that the vessels are taking an extended time to fill, which is a sign of decreased cardiac output. To assess peripheral perfusion further and detect hypovolemic shock, note the skin color, presence and quality of pulses, and temperature of the extremities.

DIF: Cognitive Level: Applying (Application) OBJ: Nursing process diagnosis

MSC: Physiologic Integrity: Basic Care and Comfort

15. Capillary refill can be assessed by applying pressure over a nail bed or a(n): a. bony prominence. b. eyelid. c. mucous membrane. d. femoral vein.

ANS: A

Capillary refill can be assessed by pressing firmly over a nail bed or bony prominence such as the chin, forehead, or sternum until the skin blanches. Count the seconds it takes for color to return. Less than 2 seconds is a normal finding, and longer than 2 seconds indicates poor perfusion.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Basic Care and Comfort

16. The secondary survey of a patient with hypotension would begin with the assessment of: a. blood type. b. level of consciousness. c. number of fractures. d. swallowing ability.

ANS: B

Secondary assessments are done after life-threatening problems are determined. For the hypotensive patient, it would be most important to begin secondary assessment of cerebral perf sion b determining the patient s le el of conscio sness.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Basic Care and Comfort

17. You would complete a Glasgow Coma Scale rating during the: a. health history. b. physical examination. c. primary survey. d. secondary survey.

ANS: D

During the secondary survey, the full range of injuries is determined. The level of consciousness is determined, and the Glasgow Coma Scale is scored as indicated.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Basic Care and Comfort

18. Mr. Stinson is a 34-year-old patient who presents to the emergency department after an auto accident. On examination, you note raccoon eyes and a positive Battle sign. Raccoon eyes and the Battle sign are associated with: a. multisystem trauma. b. orbital fractures. c. basilar skull fractures. d. subdural hematoma.

ANS: C

Raccoon eyes (bruising around the eyes) and the Battle sign (bruising behind the ears) both indicate a basilar skull fracture. Symptoms of orbital fractures are swelling of the eyelid, bruising of the eye, pain in the eye, double vision, and decreased movement of the affected eye. Signs and symptoms of a subdural hematoma are loss of consciousness after the original injury, steady or fluctuating headache, weakness, numbness or inability to speak, slurred speech, nausea, vomiting, lethargy, and seizures.

DIF: Cognitive Level: Applying (Application)

MSC: Physiologic Integrity: Basic Care and Comfort

OBJ: Nursing process diagnosis

19. A life-threatening condition is recognized with the assessment of: a. pain with downward pressure on both anterior superior iliac spines. b. guarding and intense pain with deep palpation of the abdomen. c. distant and muffled heart sounds, with distended neck veins. d. severe throbbing pain in one eye, with photophobia.

ANS: C

Distant, muffled heart sounds and distended neck veins may indicate cardiac tamponade, a life-threatening condition. Iliac spine pain indicates a pelvic fracture that may become life-threatening depending on the extent of occult bleeding. Intense pain with deep palpation is not certain to be deadly. Eye pain with photophobia signals acute glaucoma, which can lead to blindness if treatment is delayed.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Physiologic Integrity: Basic Care and Comfort

20. The application of blunt sternal pressure is used to detect: a. a fracture of attached ribs. b. the motor function of the T7 dermatome. c. pneumothorax. d. cardiac contusion.

ANS: A

OBJ: Nursing process diagnosis

Blunt sternal pressure will be painful if any attached ribs are fractured. Sternal pressure is applied to the chest to assess the stability of the chest wall.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Physiologic Integrity: Basic Care and Comfort

OBJ: Nursing process diagnosis

21. Until they are stabilized, trauma patients require reevaluation: a. every 2 minutes. b. every 5 minutes. c. every 10 minutes. d. every hour.

ANS: B

An unstable patient must be reevaluated frequently so that any new signs and symptoms are not overlooked. A primary survey should be performed every 5 minutes and the results compared with those obtained in previous surveys.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Basic Care and Comfort

22. During injury assessment, one of the most crucial historical components is: a. number of siblings. b. history of prior fractures. c. mechanism of injury. d. past and current occupational exposure.

ANS: C

In cases of trauma, the secondary assessment is intended to identify the full range of injuries, with particular focus on body systems affected by the mechanism of injury. All the other choices are not crucial for the emergency.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Basic Care and Comfort a. Bleeding ulcer b. Myocardial infarction c. Pulmonary embolism d. Transient ischemia

23. Which condition manifests as unexplained shortness of breath (SOB) and cough with hemoptysis?

ANS: C

Symptoms of pulmonary embolism include sudden onset of unexplained SOB, pleuritic chest pain, and coughing, with pink frothy sputum. Bleeding ulcer symptoms are coffee grounds emesis with gnawing pain in the upper abdomen. Myocardial infarction is signified by crushing pain in the center of the chest radiating to the arm, neck, or jaw, diaphoresis, nausea and vomiting, SOB, and a feeling of impending doom. Transient ischemia occurs with a sudden feeling of weakness and loss of movement of the arms or legs, numbness and/or tingling in any part of the body, excruciating headache, and/or difficulty speaking.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Physiologic Integrity: Basic Care and Comfort

OBJ: Nursing process diagnosis a. Age-related falls b. Motor vehicle accidents c. Work-related injuries d. Childhood play injuries

24. Which injury is the most common precipitator of blunt trauma?

ANS: B

Motor vehicle accidents account for the majority of severe blunt trauma cases.

DIF: Cognitive Level: Remembering (Knowledge)

MSC: Physiologic Integrity: Basic Care and Comfort

OBJ: Nursing process planning

25. When calculating the force of impact of a penetrating object, use: a. the size of the missile and size of the patient. b. the time of the incident and depth of the wound. c. the amount of blood loss and level of consciousness. d. the velocity of the missile and distance from the source.

ANS: D

When calculating the force of impact of a penetrating object, the amount of force is measured by the velocity of the missile and distance from the source. The force of the penetrating object on impact determines the transfer of energy.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Physiologic Integrity: Basic Care and Comfort

OBJ: Nursing process diagnosis

26. Adults and children display different physiologic responses to injury and acute illness. An important concept to remember when assessing infants and children is that they: a. experience lethal dysrhythmias first, progressing to respiratory failure. b. usually experience cardiac arrest before respiratory failure. c. usually experience respiratory arrest before circulatory failure. d. tolerate greater volume changes, with less severe consequences.

ANS: C

Cardiac arrest is rarely a primary event in children, as it is in adults. The child usually experiences respiratory and ventilatory failure that progresses to respiratory arrest first. Without rapid intervention, a cardiac arrest occurs as a secondary event.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Physiologic Integrity: Basic Care and Comfort

OBJ: Nursing process diagnosis

27. The approximate expected systolic blood pressure for a child older than 1 year is: a. 120 + child s age in ears. b. 80 + child s age in ears. c. 120 ?- child s age in ears. d. 80 + (the child s age in ears).

ANS: D

Use the eq ation 80 + (the child s age in ears) to calc late the e pected s stolic blood pressure for a child older than 1 year.

DIF: Cognitive Level: Remembering (Knowledge)

MSC: Physiologic Integrity: Basic Care and Comfort

28. In life-threatening emergencies, consent for treatment:

OBJ: Nursing process diagnosis a. is obtained before treatment to protect the facility from liability. b. is not necessary. c. occurs after treatment is administered. d. is not valid because the patient is not competent.

ANS: C

In life-threatening emergencies, the needed treatment should usually be given and formal consent obtained later.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process implementing MSC: Physiologic Integrity: Basic Care and Comfort