Ch. 11 Med Surg

LeMone/Burke/Bauldoff, Medical-Surgical Nursing 5th Edition Test Bank
Chapter 11
Question 1
Type: MCSA
A patient is brought to the emergency department with injuries sustained from a motor vehicle accident. The nurse
realizes that this patients injuries have been caused by which of the following
1. trauma
2. not wearing a seat restraint
. a drun! driver
!. not paying attention while driving
Corre"t #ns$er: "
%ationale 1# Trauma is defined as injury to human tissues and organs resulting from the transfer of energy from
the environment. Trauma encompasses a variety of injuries including those from motor vehicle crashes.
%ationale 2# There is not enough information to determine if the patient was not wearing a seat restraint$ if the
accident was caused by a drun! driver$ or if the patient was not paying attention while driving.
%ationale # There is not enough information to determine if the patient was not wearing a seat restraint$ if the
%ationale !# There is not enough information to determine if the patient was not wearing a seat restraint$ if the
&lo'al %ationale: Trauma is defined as injury to human tissues and organs resulting from the transfer of energy
from the environment. Trauma encompasses a variety of injuries including those from motor vehicle crashes.
There is not enough information to determine if the patient was not wearing a seat restraint$ if the accident was
caused by a drun! driver$ or if the patient was not paying attention while driving.
Co(niti)e Le)el: Analyzing
Client *eed: %hysiological &ntegrity
Client *eed +u':
*ursin(/,nte(rated Con"epts: 'ursing %rocess# Assessment
Learnin( -ut"o.e: ". (efine the word )trauma.*

Question 2
Type: MCSA
+eMone,-ur!e,-auldoff$ Medical-Surgical Nursing .th /dition Test -an!
Copyright 01"" by %earson /ducation$ &nc.
The spouse of a patient admitted with a gunshot wound as!s the nurse when her husband will be discharged so
that they can resume their life together. 2ith which of the following should the nurse respond to this spouse
1. )3ight now there is no way of !nowing how soon your husband can return to his previous life.*
2. )& would say in a few wee!s.*
. )%robably never.*
!. )As soon as the wound heals your husband can return to wor!.*
Corre"t #ns$er: "
%ationale 1# 'urses provide a vital lin! in both the physical and psychosocial care for the injured patient and
family. &n caring for the patient who has e4perienced trauma$ nurses must consider not only the initial physical
injury$ but also its long5term conse6uences$ including rehabilitation. Trauma may alter the patients previous way
of life$ potentially effecting independence$ mobility$ cognitive thin!ing$ and appearance. The nurse should respond
that there is no way of !nowing how soon the patient can return to his previous life.
%ationale 2# The nurse should not put a time limit of a few wee!s on the patients recovery from trauma.
%ationale # The nurse also should not tell the spouse that the patient will probably never return to his previous
life.
%ationale !# The nurse also has no way of !nowing the e4tent of the damage caused by the gunshot wound and
cannot predict when the patient can return to wor!.
&lo'al %ationale: 'urses provide a vital lin! in both the physical and psychosocial care for the injured patient
and family. &n caring for the patient who has e4perienced trauma$ nurses must consider not only the initial
physical injury$ but also its long5term conse6uences$ including rehabilitation. Trauma may alter the patients
previous way of life$ potentially effecting independence$ mobility$ cognitive thin!ing$ and appearance. The nurse
should respond that there is no way of !nowing how soon the patient can return to his previous life. The nurse
should not put a time limit of a few wee!s on the patients recovery from trauma. The nurse also should not tell
the spouse that the patient will probably never return to his previous life. The nurse also has no way of !nowing
the e4tent of the damage caused by the gunshot wound and cannot predict when the patient can return to wor!.
Co(niti)e Le)el: Applying
Client *eed: %sychosocial &ntegrity
Client *eed +u':
*ursin(/,nte(rated Con"epts: 'ursing %rocess# &mplementation
Learnin( -ut"o.e: ". (efine the word )trauma.*

Question
Type: MCMA
An elderly patient is admitted after falling on the steps at home. 2hich of the following components does the
nurse need to consider when planning care for the patient
+tandard Te/t: Select all that apply.
1. host
2. environment
. intention
!. source
5. transmission
Corre"t #ns$er: "$0$7
%ationale 1# 8ost. The host is the person or (roup at risk of in0ury. Multiple fa"tors influen"e the host1s
potential for in0ury: a(e, se/, ra"e, e"ono.i" status, pree/istin( illnesses, and use of su'stan"es su"h as
street dru(s and al"ohol. +in"e the patient is elderly, the nurse should "onsider the host $hen plannin( "are.
%ationale 2# /nvironment. The en)iron.ent in $hi"h the trau.a o""urred needs to 'e taken into
"onsideration. +in"e the patient fell on the steps at ho.e, the nurse needs to keep this in .ind $hen
plannin( "are.
%ationale # &ntention. The e)ent $as either intentional, planned, or unintentional. +in"e the patient fell on
the steps at ho.e, the e)ent $as .ost likely unintentional.
%ationale !# Source. +our"e is not a "o.ponent of a trau.ati" e)ent.
%ationale 5# Transmission. Trans.ission is not a "o.ponent of a trau.ati" e)ent.
&lo'al %ationale: The host is the person or group at ris! of injury. Multiple factors influence the hosts potential
for injury# age$ se4$ race$ economic status$ pree4isting illnesses$ and use of substances such as street drugs and
alcohol. Since the patient is elderly$ the nurse should consider the host when planning care. The environment in
which the trauma occurred needs to be ta!en into consideration. Since the patient fell on the steps at home$ the
nurse needs to !eep this in mind when planning care. The event was either intentional$ planned$ or unintentional.
Since the patient fell on the steps at home$ the event was most li!ely unintentional. Source is not a component of a
traumatic event. Transmission is not a component of a traumatic event.
Client *eed +u':
*ursin(/,nte(rated Con"epts: 'ursing %rocess# %lanning
Learnin( -ut"o.e: 0. (efine the components and types of trauma.

Question !
Type: MCSA
A patient comes into the emergency department with leg pain after falling on ice. The nurse realizes that this
patients injuries would most li!ely be classified as being which of the following
1. Class 7 minor
2. Class " minor
. Class " penetrating
!. Class 7 penetrating
Corre"t #ns$er: "
%ationale 1# Trauma patients are classified as Class "$ 0$ or 7 based on factors including mechanism of injury$
vehicle speed$ height of falls$ and location of penetrating injuries. Class 7 trauma is the least severe. An e4ample
would be a same level fall without loss of consciousness or significant injury. The patient who slipped and fell on
ice is an e4ample of a Class 7 trauma.
%ationale 2# Class " trauma involves life5threatening injuries li!ely to re6uire medical specialists or immediate
surgical intervention. The patient did not sustain a Class " injury. Minor trauma causes injury to a single part or
system of the body and is usually treated in a physicians office or in the hospital emergency department. A single
bone fracture$ small second5degree burns$ or a laceration re6uiring sutures are e4amples of minor trauma. Since
the patient is e4periencing leg pain after the fall$ the injury would be considered minor.
%ationale # %enetrating trauma occurs when a foreign object enters the body causing damage to body structures.
The patient fell and did not sustain a penetrating injury.
%ationale !# %enetrating trauma occurs when a foreign object enters the body causing damage to body structures.
The patient fell and did not sustain a penetrating injury.
&lo'al %ationale: Trauma patients are classified as Class "$ 0$ or 7 based on factors including mechanism of
injury$ vehicle speed$ height of falls$ and location of penetrating injuries. Class 7 trauma is the least severe. An
e4ample would be a same level fall without loss of consciousness or significant injury. The patient who slipped
and fell on ice is an e4ample of a Class 7 trauma. Class " trauma involves life5threatening injuries li!ely to re6uire
medical specialists or immediate surgical intervention. The patient did not sustain a Class " injury. Minor trauma
causes injury to a single part or system of the body and is usually treated in a physicians office or in the hospital
emergency department. A single bone fracture$ small second5degree burns$ or a laceration re6uiring sutures are
e4amples of minor trauma. Since the patient is e4periencing leg pain after the fall$ the injury would be considered
minor. %enetrating trauma occurs when a foreign object enters the body causing damage to body structures. The
patient fell and did not sustain a penetrating injury.
Client *eed +u':

Question 5
Type: MCSA
A patient is brought to the emergency department with injuries sustained from a wall that collapsed in the home.
The nurse realizes that this patients injuries are most li!ely caused by which of the following
1. crushing
2. shearing
. deceleration
!. blast
Corre"t #ns$er: "
%ationale 1# -lunt trauma occurs when there is communication between tissues and outside environment. A
crushing injury occurs from a high force that leads to tissue destruction. The wall collapse on the patient most
li!ely has injuries caused by crushing.
%ationale 2# Shearing occurs when structures slip across each other.
%ationale # (eceleration is the decrease of speed of a moving object.
%ationale !# -last injuries result from the temperature and velocity of air movement and the force of projectiles
from the e4plosion.
&lo'al %ationale: -lunt trauma occurs when there is communication between tissues and outside environment. A
crushing injury occurs from a high force that leads to tissue destruction. The wall collapse on the patient most
li!ely has injuries caused by crushing. Shearing occurs when structures slip across each other. (eceleration is the
decrease of speed of a moving object. -last injuries result from the temperature and velocity of air movement and
the force of projectiles from the e4plosion.
Client *eed +u':

Question 2
Type: MCSA
A patient was admitted with a head injury caused by rapid acceleration and deceleration. The nurse realizes that
the patients injuries could also be classified as being which of the following
1. blunt
2. shearing
. blast
!. minor
Corre"t #ns$er: "
%ationale 1# -lunt trauma occurs when there is no communication between the damaged tissues and the outside
environment. &t is caused by various forces including deceleration$ acceleration$ shearing, compression$ and
crushing. Since the head injury was caused by acceleration and deceleration$ this injury could be classified as
being from blunt trauma.
%ationale 2# Shearing is a type of blunt trauma.
%ationale # -last injuries result from the temperature and velocity of air movement and the force of projectiles
from the e4plosion.
%ationale !# Minor trauma causes injury to a single part or system of the body and is usually treated in a
physicians office or in the hospital emergency department.
&lo'al %ationale: -lunt trauma occurs when there is no communication between the damaged tissues and the
outside environment. &t is caused by various forces including deceleration$ acceleration$ shearing, compression$
and crushing. Since the head injury was caused by acceleration and deceleration$ this injury could be classified as
being from blunt trauma. Shearing is a type of blunt trauma. -last injuries result from the temperature and
velocity of air movement and the force of projectiles from the e4plosion. Minor trauma causes injury to a single
part or system of the body and is usually treated in a physicians office or in the hospital emergency department.
Client *eed +u':

Question 3
Type: MCSA
A patient is admitted with a thermal injury. The mechanism of injury that this patient most li!ely e4perienced
would be which of the following
1. fire
2. lightning
. ultraviolet radiation
!. gunshot
Corre"t #ns$er: "
%ationale 1# The energy source for the patients injury is thermal. Mechanisms of injury for thermal injuries
include fire$ heating appliances$ and freezing temperatures.
%ationale 2# The energy source for lightning is electrical.
%ationale # The energy source for ultraviolet radiation is physical.
%ationale !# The energy source for a gunshot is mechanical.
&lo'al %ationale: The energy source for the patients injury is thermal. Mechanisms of injury for thermal injuries
include fire$ heating appliances$ and freezing temperatures. The energy source for lightning is electrical. The
energy source for ultraviolet radiation is physical. The energy source for a gunshot is mechanical.
Client *eed +u':
Learnin( -ut"o.e: 7. (escribe the result of energy transfer to the human body.

Question 4
Type: MCSA
A pediatric patient is admitted after ingesting a household cleaning solution. The nurse realizes that the energy
source for this patients injuries would be which of the following
1. chemical
2. physical
. thermal
!. mechanical
Corre"t #ns$er: "
%ationale 1# The mechanism of injury for drugs$ poisons$ and industrial chemicals is chemical.
%ationale 2# The mechanism of injury for physical assault$ drowning$ or e4plosions would be physical.
%ationale # The mechanism of injury for heating appliances$ fire$ or freezing temperatures would be thermal.
%ationale !# The mechanism of injury for motor vehicle accidents would be mechanical.
&lo'al %ationale: The mechanism of injury for drugs$ poisons$ and industrial chemicals is chemical. The
mechanism of injury for physical assault$ drowning$ or e4plosions would be physical. The mechanism of injury
for heating appliances$ fire$ or freezing temperatures would be thermal. The mechanism of injury for motor
vehicle accidents would be mechanical.
Client *eed +u':

Question 5
Type: MCSA
A patient recovering from a motor vehicle accident as!s the nurse why he has so many injuries since the other car
)barely* hit him. 2ith which of the following should the nurse respond to the patient
1. )The car that hit you transferred a large amount of energy to your body causing injuries.*
2. )9ou have other health problems that ma!e the injuries worse.*
. )The driver of the other car intended to hit you.*
!. )Since you are older$ your injuries will be worse.*
Corre"t #ns$er: "
%ationale 1# The nurse needs to respond with a statement that e4plains the transfer of energy to the patients body
causing injuries.
%ationale 2# The response that addresses the patients other health problems and age would not e4plain the
transfer of energy but rather identifies characteristics of the host.
%ationale # The response that the driver of the other car intended to injure the patient addresses the intention of
the trauma and not the transfer of energy.
%ationale !# The response that addresses the patients other health problems and age would not e4plain the
transfer of energy but rather identifies characteristics of the host.
&lo'al %ationale: The nurse needs to respond with a statement that e4plains the transfer of energy to the
patients body causing injuries. The response that addresses the patients other health problems and age would not
e4plain the transfer of energy but rather identifies characteristics of the host. The response that the driver of the
other car intended to injure the patient addresses the intention of the trauma and not the transfer of energy.
Client *eed +u':

Question 16
Type: MCSA
A construction wor!er was admitted after falling from the roof of a building. The energy source for this patients
injuries was most li!ely caused by which of the following
1. gravity
2. mechanical
. physical
!. electrical
Corre"t #ns$er: "
%ationale 1# The energy source for a fall is gravity.
%ationale 2# The energy source for motor vehicle accidents is mechanical.
%ationale # The energy source for physical assaults$ e4plosions$ and drowning is physical.
%ationale !# The energy source for lightning is electrical.
&lo'al %ationale: The energy source for a fall is gravity. The energy source for motor vehicle accidents is
mechanical. The energy source for physical assaults$ e4plosions$ and drowning is physical. The energy source for
lightning is electrical.
Client *eed +u':

Question 11
Type: MCSA
A patient is admitted to the hospital with injuries from a motor vehicle collision. (uring the nurses initial
assessment$ the patient develops hypotension$ and severe jugular distension with a tracheal deviation. 2hich of
the following should the nurse suspect is occurring with this patient
1. tension pneumothora4
2. hemorrhage
. compensatory shoc!
!. hypovolemic shoc!
Corre"t #ns$er: "
%ationale 1# A tension pneumothora4 is life5threatening and re6uires immediate intervention. :n inspiration$ air
enters the pleural space$ does not escape on e4piration$ and increases the intrapleural pressure. This pressure
collapses the injured lung and shifts the mediastinal contents$ compressing the heart$ great vessels$ trachea$ and
eventually the uninjured lung.
%ationale 2# The patient would not have jugular vein distention with a hemorrhage$ compensatory shoc!$ or
hypovolemic shoc!.
%ationale # The patient would not have jugular vein distention with a hemorrhage$ compensatory shoc!$ or
hypovolemic shoc!.
%ationale !# The patient would not have jugular vein distention with a hemorrhage$ compensatory shoc!$ or
hypovolemic shoc!.
&lo'al %ationale: A tension pneumothora4 is life5threatening and re6uires immediate intervention. :n
inspiration$ air enters the pleural space$ does not escape on e4piration$ and increases the intrapleural pressure. This
pressure collapses the injured lung and shifts the mediastinal contents$ compressing the heart$ great vessels$
trachea$ and eventually the uninjured lung. The patient would not have jugular vein distention with a hemorrhage$
compensatory shoc!$ or hypovolemic shoc!.
Client *eed +u':
Learnin( -ut"o.e: ;. (iscuss causes$ effects$ and initial management of trauma.

Question 12
Type: MCSA
A patient is admitted with a diagnosis of blunt trauma to the abdomen after a motor vehicle collision. 2hich of the
following should the nurse assess first when the patient arrives in the emergency department
1. airway patency
2. abdomen for any abnormalities
. cervical spine for tenderness
!. signs of neurological deficits
Corre"t #ns$er: "
%ationale 1# Assessment of the airway is the highest priority in the trauma patient. Assessment includes
determining airway patency. &f the patient is unresponsive$ manual opening of the airway using a jaw thrust or
chin lift maneuver is necessary. :nce the airway is opened$ the practitioner must identify any potential obstruction
from the tongue$ loose teeth$ foreign bodies$ bleeding$ secretions$ vomitus$ or edema. &f the patient is responsive
and can vocalize$ that is a good indication that the airway is clear.
%ationale 2# All of the other responses are important$ but certainly the nurse should address airway initially.
%ationale # The nurse should assess the cervical spine area after initial A-C assessment.
%ationale !# The nurse is always concerned about the neurological assessment of a patient$ but this patient has a
blunt trauma injury from a motor vehicle< therefore$ this would not be the initial assessment for the patient.
&lo'al %ationale: Assessment of the airway is the highest priority in the trauma patient. Assessment includes
determining airway patency. &f the patient is unresponsive$ manual opening of the airway using a jaw thrust or
chin lift maneuver is necessary. :nce the airway is opened$ the practitioner must identify any potential obstruction
from the tongue$ loose teeth$ foreign bodies$ bleeding$ secretions$ vomitus$ or edema. &f the patient is responsive
and can vocalize$ that is a good indication that the airway is clear. All of the other responses are important$ but
certainly the nurse should address the airway initially. The nurse should assess the cervical spine area after initial
A-C assessment. The nurse is always concerned about the neurological assessment of a patient$ but this patient
has a blunt trauma injury from a motor vehicle< therefore$ this would not be the initial assessment for the patient.
Client *eed +u':

Question 1
Type: MCSA
A patient is brought to the emergency department with a penetrating wound to the nec!. The patient is dyspneic
and cyanotic$ and has evidence of subcutaneous emphysema. 2hat does the nurse e4pect the physician to do
initially
1. &ntubate the patient because of the severe wound.
2. 'otify the ne4t of !in regarding the patients condition.
. :rder 45rays of the lumbar area to assess for fractures.
!. Administer a beta bloc!er to alleviate the sympathetic response.
Corre"t #ns$er: "
%ationale 1# %enetrating trauma to the nec! is associated with a high degree of morbidity and mortality. Airway
involvement includes dyspnea$ cyanosis$ subcutaneous emphysema$ hoarseness$ or air bubbling from the wound.
The !ey is early identification of the need for intubation before the patient has no airway at all.
%ationale 2# The physician will most li!ely do or prescribe the other options however the most important is to
maintain the airway.
%ationale # The physician will most li!ely do or prescribe the other options however the most important is to
%ationale !# The physician will most li!ely do or prescribe the other options however the most important is to
&lo'al %ationale: %enetrating trauma to the nec! is associated with a high degree of morbidity and mortality.
Airway involvement includes dyspnea$ cyanosis$ subcutaneous emphysema$ hoarseness$ or air bubbling from the
wound. The !ey is early identification of the need for intubation before the patient has no airway at all. The
physician will most li!ely do or prescribe the other options however the most important is to maintain the airway.
Client *eed +u':

Question 1!
Type: MCSA
The nurse suspects that a patient who was in a motor vehicle accident does not have a cervical spine injury when
which of the following is assessed
1. alert without midline cervical tenderness
2. no motor response of lower e4tremities
. lac! of deep tendon refle4es
!. lethargic and confused
Corre"t #ns$er: "
%ationale 1# There is a decreased probability of a cervical spine injury if the following criteria are met# absence
of midline cervical spine tenderness< normal alertness< absence of into4ication< absence of a painful distracting
injury< and no focal neurological defects.
%ationale 2# A lac! of motor response$ lac! of deep tendon refle4es$ lethargy$ and confusion would be indications
of a cervical spine injury.
%ationale # A lac! of motor response$ lac! of deep tendon refle4es$ lethargy$ and confusion would be indications
%ationale !# A lac! of motor response$ lac! of deep tendon refle4es$ lethargy$ and confusion would be indications
&lo'al %ationale: There is a decreased probability of a cervical spine injury if the following criteria are met#
absence of midline cervical spine tenderness< normal alertness< absence of into4ication< absence of a painful
distracting injury< and no focal neurological defects. A lac! of motor response$ lac! of deep tendon refle4es$
lethargy$ and confusion would be indications of a cervical spine injury.
Client *eed +u':

Question 15
Type: MCSA
A patient is brought to the emergency department with physical injuries sustained from a gang fight. The patients
blood pressure is =1,.1 mm8g with a pulse of "01 and thready. The nurse realizes that the diagnostic test that
would provide the fastest information to help this patient would be which of the following
1. sonogram
2. complete blood count
. urinalysis
!. serum electrolyte levels
Corre"t #ns$er: "
%ationale 1# The focused assessment by sonography in trauma or >AST identifies blood in body cavities where it
is not supposed to be. The primary focus is on the peritoneum. Since the patient was in a fight and has a low blood
pressure and thready pulse$ this diagnostic test would provide the fastest information to help the patient.
%ationale 2# A complete blood count$ urinalysis$ and serum electrolyte levels would not provide the fastest
information for this patient.
%ationale # A complete blood count$ urinalysis$ and serum electrolyte levels would not provide the fastest
%ationale !# A complete blood count$ urinalysis$ and serum electrolyte levels would not provide the fastest
&lo'al %ationale: The focused assessment by sonography in trauma or >AST identifies blood in body cavities
where it is not supposed to be. The primary focus is on the peritoneum. Since the patient was in a fight and has a
low blood pressure and thready pulse$ this diagnostic test would provide the fastest information to help the
patient. A complete blood count$ urinalysis$ and serum electrolyte levels would not provide the fastest information
for this patient.
Client *eed +u':

Question 12
Type: MCSA
A patient is admitted with possible head and spinal cord injuries sustained after falling from a ladder. The
diagnostic test that will identify the type and e4tent of injuries for this patient would be which of the following
1. magnetic resonance imaging
2. cervical spine 45rays
. spinal cord 45rays
!. cerebral angiogram
Corre"t #ns$er: "
%ationale 1# Magnetic resonance imaging scans discover injuries to the brain and spinal cord. This is the
diagnostic test that should be done for this patient.
%ationale 2# Cervical spine and spinal cord 45rays can detect fractures of the vertebra but will not detect injuries
to the brain.
%ationale # Cervical spine and spinal cord 45rays can detect fractures of the vertebra but will not detect injuries
to the brain.
%ationale !# A cerebral angiogram can detect injuries to the brain but not of the spinal cord.
&lo'al %ationale: Magnetic resonance imaging scans discover injuries to the brain and spinal cord. This is the
diagnostic test that should be done for this patient. Cervical spine and spinal cord 45rays can detect fractures of the
vertebra but will not detect injuries to the brain. A cerebral angiogram can detect injuries to the brain but not of
the spinal cord.
Client *eed +u':
Learnin( -ut"o.e: .. (iscuss diagnostic tests used in assessing patients e4periencing trauma and shoc!.

Question 13
Type: MCMA
A victim of a multi5vehicle automobile accident is brought into the emergency department. The patient has slurred
speech and is lethargic. The nurse realizes that which of the following diagnostic tests would be indicated for this
patient
1. blood alcohol level
2. erine drug screen
. s!ull 45rays
!. chest 45ray
5. urinalysis
Corre"t #ns$er: "$0
%ationale 1# -lood alcohol level. +in"e al"ohol alters a person1s le)el of "ons"iousness, the patient $ith
slurred spee"h and lethar(y $ould .ost likely ha)e a 'lood al"ohol le)el done.
%ationale 2# ?rine drug screen. +i.ilar to al"ohol, so.e dru(s "an "ause lethar(y and slurred spee"h. The
patient $ould .ost like ha)e a urine dru( s"reen done.
%ationale # S!ull 45rays. This dia(nosti" test .ay or .ay not 'e indi"ated for the patient.
%ationale !# Chest 45ray. This dia(nosti" test $ill .ost likely 'e done ho$e)er not 'e"ause of slurred spee"h
or lethar(y.
%ationale 5# ?rinalysis. This dia(nosti" test $ill .ost likely 'e done ho$e)er not 'e"ause of slurred spee"h
or lethar(y.
&lo'al %ationale: Blood al"ohol le)el. Since alcohol alters a persons level of consciousness$ the patient with
slurred speech and lethargy would most li!ely have a blood alcohol level done. Similar to alcohol$ some drugs can
cause lethargy and slurred speech. The patient would most li!e have a urine drug screen done. +kull /7rays may
or may not be indicated for the patient. Chest /7ray will most li!ely be done however not because of slurred
speech or lethargy. 8rinalysis will most li!ely be done however not because of slurred speech or lethargy.
Client *eed +u':

Question 14
Type: MCSA
The nurse determines that a patient is having ongoing progression of a shoc! state when which of the following is
assessed
1. decrease in serum glucose level
2. drop in blood urea nitrogen level
. increased eosinophil level
!. low serum cardiac enzyme level
Corre"t #ns$er: "
%ationale 1# Serum electrolyte levels will be assessed to monitor the severity and progression of shoc!. As shoc!
progresses$ serum glucose levels will decrease.
%ationale 2# A drop in blood urea nitrogen level means the !idneys are receiving ade6uate blood flow.
%ationale # An increase in eosinophils indicates an allergic response.
%ationale !# +ow serum cardiac enzymes indicate no myocardial damage.
&lo'al %ationale: Serum electrolyte levels will be assessed to monitor the severity and progression of shoc!. As
shoc! progresses$ serum glucose levels will decrease. A drop in blood urea nitrogen level means the !idneys are
receiving ade6uate blood flow. An increase in eosinophils indicates an allergic response. +ow serum cardiac
enzymes indicate no myocardial damage.
Client *eed +u':

Question 15
Type: MCSA
A patient with multiple traumatic injuries has e4perienced severe blood loss and is prescribed to receive blood
immediately. The nurse realizes that since there is not sufficient time for type and crossmatch$ the patient will
most li!ely receive which type of blood
1. :
2. A
. -
!. A-
Corre"t #ns$er: "
%ationale 1# Type : blood is the universal donor. A-: antibodies develop in the serum of people whose 3-Cs
lac! the corresponding antigen< these antibodies are called anti5A and anti5-.
%ationale 2# The person with blood type - has A antibodies$ the person with type A has - antibodies$ the person
with type : has both types of antibodies$ and the person with A- has no antibodies< therefore$ this patient is
!nown as the universal recipient.
%ationale # The person with blood type - has A antibodies$ the person with type A has - antibodies$ the person
%ationale !# The person with blood type - has A antibodies$ the person with type A has - antibodies$ the person
&lo'al %ationale: Type : blood is the universal donor. A-: antibodies develop in the serum of people whose
3-Cs lac! the corresponding antigen< these antibodies are called anti5A and anti5-. The person with blood type -
has A antibodies$ the person with type A has - antibodies$ the person with type : has both types of antibodies$
and the person with A- has no antibodies< therefore$ this patient is !nown as the universal recipient.
Client *eed: Safe /ffective Care /nvironment
Client *eed +u':
Learnin( -ut"o.e: @. (escribe collaborative interventions for patients e4periencing trauma and shoc!$
including medications$ blood transfusion$ and intravenous fluids.

Question 26
Type: MCSA
A patient with multiple gun shot wounds to the abdomen has received eight units of blood. The blood ban!
notifies the nurse that they have run out of blood for the patient. The nurse understands that the patient can receive
any type of blood if the patient has which blood type
1. A-
2. A
. -
!. :
Corre"t #ns$er: "
%ationale 1# The person with blood type A has - antibodies$ someone with type - has A antibodies$ someone
with type A- has no antibodies$ and a person who has type : blood has both antibodies. Therefore$ the person
with type A- blood can receive any type of blood in an emergency situation and is referred to as the universal
recipient.
%ationale 2# The person with blood type A has - antibodies$ someone with type - has A antibodies$ someone
with type A- has no antibodies$ and a person who has type : blood has both antibodies.
%ationale # The person with blood type A has - antibodies$ someone with type - has A antibodies$ someone
with type A- has no antibodies$ and a person who has type : blood has both antibodies.
%ationale !# A person with the : blood type is considered a universal donor in an emergency situation.
&lo'al %ationale: The person with blood type A has - antibodies$ someone with type - has A antibodies$
someone with type A- has no antibodies$ and a person who has type : blood has both antibodies. Therefore$ the
person with type A- blood can receive any type of blood in an emergency situation and is referred to as the
universal recipient. A person with the : blood type is considered a universal donor in an emergency situation.
Client *eed +u':

Question 21
Type: MCSA
A patient$ admitted with multiple injuries$ is prescribed to receive an intravenous colloid solution. 2hich one of
the following solutions would be appropriate for the nurse to infuse
1. 0.A albumin
2. 1.BA normal saline
. (e4trose .A and 1.;. A normal saline
!. (e4trose .A and water
Corre"t #ns$er: "
%ationale 1# Colloid solutions contain substances that should not diffuse through capillary walls. Colloids tend to
remain in the vascular system and increase the osmotic pressure of the serum$ causing fluid to move into the
vascular compartment from the interstitial space. As a result$ plasma volume e4pands. Colloid solutions used to
treat shoc! include .A albumin$ 0.A albumin$ hetastarch$ plasma protein fraction$ and de4tran.
%ationale 2# Crystalloid solutions contain de4trose or electrolytes such as normal saline dissolved in water< they
are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and the
interstitial space.
%ationale # Crystalloid solutions contain de4trose or electrolytes such as normal saline dissolved in water< they
interstitial space.
%ationale !# Crystalloid solutions contain de4trose or electrolytes such as normal saline dissolved in water< they
interstitial space.
&lo'al %ationale: Colloid solutions contain substances that should not diffuse through capillary walls. Colloids
tend to remain in the vascular system and increase the osmotic pressure of the serum$ causing fluid to move into
the vascular compartment from the interstitial space. As a result$ plasma volume e4pands. Colloid solutions used
to treat shoc! include .A albumin$ 0.A albumin$ hetastarch$ plasma protein fraction$ and de4tran. Crystalloid
solutions contain de4trose or electrolytes such as normal saline dissolved in water< they are either isotonic or
hypotonic. All crystalloid solutions increase fluid volume in the intravascular and the interstitial space.
Client *eed +u':

Question 22
Type: MCSA
A patient diagnosed with hypovolemic shoc! is prescribed intravenous fluids while awaiting blood transfusions.
The nurse realizes that the solution of choice for this patient would be which of the following
1. 3ingers lactate
2. (e4trose .A and water
. (e4trose .A and 1.;.A normal saline
!. (e4trose .A and 1.BA normal saline
Corre"t #ns$er: "
%ationale 1# 3ingers lactate and 1.BA saline are the fluids of choice in treating hypovolemic shoc!$ especially in
the emergency phase of care while blood is being typed and crossmatched. +arge amounts of these solutions may
be infused rapidly$ increasing blood volume and tissue perfusion.
%ationale 2# 8ypotonic crystalloid solutions$ such as (e4trose .A in water or normal saline$ increase fluid
volume in both the intravascular and interstitial spaces. -ut since appro4imately 0.A of the fluid stays within the
intravascular space$ there is an increased ris! of peripheral edema.
%ationale # 8ypotonic crystalloid solutions$ such as (e4trose .A in water or normal saline$ increase fluid
%ationale !# 8ypotonic crystalloid solutions$ such as (e4trose .A in water or normal saline$ increase fluid
&lo'al %ationale: 3ingers lactate and 1.BA saline are the fluids of choice in treating hypovolemic shoc!$
especially in the emergency phase of care while blood is being typed and crossmatched. +arge amounts of these
solutions may be infused rapidly$ increasing blood volume and tissue perfusion. 8ypotonic crystalloid solutions$
such as (e4trose .A in water or normal saline$ increase fluid volume in both the intravascular and interstitial
spaces. -ut since appro4imately 0.A of the fluid stays within the intravascular space$ there is an increased ris! of
peripheral edema.
Client *eed +u':

Question 2
Type: MCSA
A patient diagnosed with shoc! is prescribed dobutamine C(obutre4D. 2hich of the following would the nurse
assess as an effect of this medication
1. increased heart rate
2. reduced heart rate
. decreased respiratory rate
!. decreased blood pressure
Corre"t #ns$er: "
%ationale 1# (obutamine C(obutre4D is a medication that mimics the fight5or5flight response of the sympathetic
nervous system. The physiologic effect is improved perfusion and o4ygenation of the heart$ with increased stro!e
volume and heart rate$ and increased cardiac output. &ncreased cardiac output in turn increases tissue perfusion
and o4ygenation.
%ationale 2# This medication will not decrease the heart rate$ decrease the respiratory rate$ nor decrease the blood
pressure.
%ationale # This medication will not decrease the heart rate$ decrease the respiratory rate$ nor decrease the blood
pressure.
%ationale !# This medication will not decrease the heart rate$ decrease the respiratory rate$ nor decrease the blood
pressure.
&lo'al %ationale: (obutamine C(obutre4D is a medication that mimics the fight5or5flight response of the
sympathetic nervous system. The physiologic effect is improved perfusion and o4ygenation of the heart$ with
increased stro!e volume and heart rate$ and increased cardiac output. &ncreased cardiac output in turn increases
tissue perfusion and o4ygenation. This medication will not decrease the heart rate$ decrease the respiratory rate$
nor decrease the blood pressure.
Client *eed +u':
*ursin(/,nte(rated Con"epts: 'ursing %rocess# /valuation

Question 2!
Type: MCSA
The nurse is preparing to administer intravenous nitroglycerin to a patient diagnosed with cardiogenic shoc!.
2hich of the following should the nurse do when providing this medication
1. ?se an infusion pump.
2. Administer with %EC tubing.
. ?se within = hours of reconstitution.
!. %atient permitted out of bed with assist only.
Corre"t #ns$er: "
%ationale 1# &ntravenous nitroglycerin must be mi4ed in glass bottles and infused through special$ non5%EC
tubing$ because up to ;1A to =1A of nitroglycerin can be absorbed by %EC bags or tubing.
%ationale 2# &ntravenous nitroglycerin must be mi4ed in glass bottles and infused through special$ non5%EC
tubing$ because up to ;1A to =1A of nitroglycerin can be absorbed by %EC bags or tubing.
%ationale # This medication must be infused with an infusion pump$ and used within four hours of
reconstitution.
%ationale !# The patient receiving intravenous nitroglycerin should be on bedrest and not assisted out of bed.
&lo'al %ationale: &ntravenous nitroglycerin must be mi4ed in glass bottles and infused through special$ non5
%EC tubing$ because up to ;1A to =1A of nitroglycerin can be absorbed by %EC bags or tubing. This medication
must be infused with an infusion pump$ and used within four hours of reconstitution. The patient receiving
intravenous nitroglycerin should be on bed rest and not assisted out of bed.
Client *eed +u':

Question 25
Type: MCMA
2hich of the following assessment findings would be seen in a patient who e4perienced a traumatic brain injury
and is being evaluated for brain death
1. absence of gag or corneal refle4
2. absence of oculovestibular refle4
. apnea with %aC:0 of @@ mm8g
!. to4ic metabolic disorders
5. response to deep stimuli
Corre"t #ns$er: "$0$7
%ationale 1# Absence of gag or corneal refle4. This is a "lini"al si(n that is "onsistent $ith 'rain death.
%ationale 2# Absence of oculovestibular refle4. This is a "lini"al si(n that is "onsistent $ith 'rain death.
%ationale # Apnea with %aC:0 of @@ mm 8g. This is a "lini"al si(n that is "onsistent $ith 'rain death.
%ationale !# To4ic metabolic disorders. This is not a si(n that is "onsistent $ith 'rain death.
%ationale 5# 3esponse to deep stimuli. This is not a si(n that is "onsistent $ith 'rain death.
&lo'al %ationale: Absence of gag or corneal refle4$ absence of oculovestibular refle4$ and apnea with %aC:0 of
@@ mm8g are clinical signs consistent with brain death. To4ic metabolic disorders and response to deep stimuli
are not a signs consistent with brain death.
Client *eed +u':
Learnin( -ut"o.e: F. (iscuss organ donation and forensic implications of traumatic injury or death.

Question 22
Type: MCSA
The spouse of a patient admitted with severe spinal cord injuries tells the nurse that she believes her husband is
going to recover since he continues to ma!e movements that occur without stimulation. 2hich of the following
should the nurse e4plain to the spouse
1. )2ith spinal cord injuries$ the patient can continue to ma!e movements which are refle4es but do not reflect
brain function.*
2. )The patient will most li!ely recover in time.*
. )As long as he has o4ygen to the brain$ he will recover.*
!. )8is movements indicate that his brain is dead.*
Corre"t #ns$er: "
%ationale 1# :ne criteria of brain death is the lac! of spontaneous movement$ however$ some spinal cord refle4es
may be present. This is what the nurse should e4plain to the spouse regarding the patients movements.
%ationale 2# The nurse should not tell the spouse that the patient will recover in time or will recover as long as he
has o4ygen to the brain.
%ationale # The nurse should not tell the spouse that the patient will recover in time or will recover as long as he
has o4ygen to the brain.
%ationale !# The patient has severe spinal cord injuries. Telling the spouse that the patients movements indicate
that the patients brain is dead is in inappropriate response.
&lo'al %ationale: :ne criterion of brain death is the lac! of spontaneous movement$ however$ some spinal cord
refle4es may be present. This is what the nurse should e4plain to the spouse regarding the patients movements.
The nurse should not tell the spouse that the patient will recover in time or will recover as long as he has o4ygen
to the brain. The patient has severe spinal cord injuries. Telling the spouse that the patients movements indicate
that the patients brain is dead is in inappropriate response.
Client *eed +u':

Question 23
Type: MCSA
A patient is brought to the emergency department with gunshot wounds to the abdomen and lower e4tremities. To
protect the chain of evidence for these injuries$ which of the following should the nurse do
1. 3emove the patients clothing and place in a breathable bag.
2. Cover the patients hands with plastic bags.
. Cut off the patients clothing and bathe the s!in and wounds as soon as possible.
!. %lace clothing and other patient items on a bedside table and have a nursing assistant remove when possible.
Corre"t #ns$er: "
%ationale 1# /ach item of clothing removed from the patient must be placed in a breathable container$ such as a
paper bag$ and documented appropriately.
%ationale 2# The patients hands should be covered with plastic bags only if the patient died.
%ationale # The clothing should not be cut off in order to bathe the patients s!in and wounds.
%ationale !# The patients clothing and personal items should not be left on a bedside table waiting for someone
else to remove. This would not protect the chain of evidence.
&lo'al %ationale: /ach item of clothing removed from the patient must be placed in a breathable container$ such
as a paper bag$ and documented appropriately. The clothing should not be cut off in order to bathe the patients
s!in and wounds. The patients clothing and personal items should not be left on a bedside table waiting for
someone else to remove. This would not protect the chain of evidence. The patients hands should be covered with
plastic bags only if the patient died.
Client *eed +u':

Question 24
Type: MCSA
An adult patient who has died from traumatic injuries is an organ donor. 2hich of the following should the nurse
do when caring for this patient
1. Maintain systolic blood pressure of B1 mm8g.
2. Geep o4ygen saturation level at F.A.
. %rovide intravenous fluids for a urine output to be 0. m+ per hour.
!. %rovide e4ternal cardiac compressions to achieve a heart rate of @1 beats per minute.
Corre"t #ns$er: "
%ationale 1# 2hen caring for an adult patient who is an organ donor$ the nurse should# maintain systolic blood
pressure of B1 mm8g to !eep the patients organs perfused until removal < maintain urine output at more than 71
m+ per hour< and maintain o4ygen saturation at B1A or greater.
%ationale 2# 2hen caring for an adult patient who is an organ donor$ the nurse should maintain systolic blood
pressure of B1 mm8g to !eep the patients organs perfused until removal$ maintain urine output at more than 71
m+ per hour$ and maintain o4ygen saturation at B1A or greater.
%ationale # 2hen caring for an adult patient who is an organ donor$ the nurse should maintain systolic blood
pressure of B1 mm8g to !eep the patients organs perfused until removal$ maintain urine output at more than 71
m+ per hour$ and maintain o4ygen saturation at B1A or greater.
%ationale !# /4ternal cardiac compressions should not be provided to achieve a heart rate of @1 beats per minute.
&lo'al %ationale: 2hen caring for an adult patient who is an organ donor$ the nurse should maintain systolic
blood pressure of B1 mm8g to !eep the patients organs perfused until removal$ maintain urine output at more
than 71 m+ per hour$ and maintain o4ygen saturation at B1A or greater. /4ternal cardiac compressions should not
be provided to achieve a heart rate of @1 beats per minute.
Client *eed +u':

Question 25
Type: MCSA
A patient with traumatic injuries has lost appro4imately 711 m+ of blood. The nurse realizes that which of the
following will most li!ely be assessed in this patient
1. slight increase in heart rate
2. nonpalpable peripheral pulses
. narrowing pulse pressure
!. increase in blood glucose level
Corre"t #ns$er: "
%ationale 1# 2ith a slight decrease in circulating blood volume usually less than .11 m+ the symptoms of shoc!
are almost imperceptible. The pulse rate may be slightly elevated. &f the injury is minor or of short duration$
arterial pressure is usually maintained and no further symptoms occur.
%ationale 2# 'onpalpable peripheral pulses$ narrowing pulse pressure$ and an increase in blood glucose level are
all seen in progressive shoc!.
%ationale # 'onpalpable peripheral pulses$ narrowing pulse pressure$ and an increase in blood glucose level are
%ationale !# 'onpalpable peripheral pulses$ narrowing pulse pressure$ and an increase in blood glucose level are
&lo'al %ationale: 2ith a slight decrease in circulating blood volume usually less than .11 m+ the symptoms of
shoc! are almost imperceptible. The pulse rate may be slightly elevated. &f the injury is minor or of short duration$
arterial pressure is usually maintained and no further symptoms occur. 'onpalpable peripheral pulses$ narrowing
pulse pressure$ and an increase in blood glucose level are all seen in progressive shoc!.
Client *eed +u':
Learnin( -ut"o.e: =. (iscuss cellular homeostasis and basic hemodynamics.

Question 6
Type: MCSA
The nurse wants to calculate a patients mean arterial pressure. 2hich of the following vital signs would the nurse
use to ma!e this calculation
1. blood pressure
2. temperature
. respirations
!. heart rate
Corre"t #ns$er: "
%ationale 1#
%ationale 2#
%ationale #
%ationale !#
&lo'al %ationale: The mean arterial pressure can be calculated by multiplying the diastolic blood pressure by 0$
adding the systolic pressure$ and dividing this total by 7. The patients blood pressure is needed to ma!e this
calculation. The temperature$ respirations$ and heart rate are not used to calculate mean arterial pressure.
Client *eed +u':

Question 1
Type: MCSA
The nurse is providing medications to increase a patients system vascular resistance. At which point will the
nurse !now that the patient has ade6uate tissue perfusion
1. mean arterial pressure reaches @1
2. mean arterial pressure reaches B1
. blood pressure reaches "01,=1 mm8g
!. urine output is "1 m+ per hour
Corre"t #ns$er: "
%ationale 1# A mean arterial pressure of @1 mm8g is re6uired to maintain ade6uate perfusion to the brain$ heart$
and !idneys.
%ationale 2# A mean arterial pressure of B1 is considered within normal limits.
%ationale # A blood pressure of "01,=1 mm8g is considered normal.
%ationale !# A urine output of "1 m+ per hour would not indicate ade6uate renal perfusion.
&lo'al %ationale: A mean arterial pressure of @1 mm8g is re6uired to maintain ade6uate perfusion to the brain$
heart$ and !idneys. A mean arterial pressure of B1 is considered within normal limits. A blood pressure of "01,=1
mm8g is considered normal. A urine output of "1 m+ per hour would not indicate ade6uate renal perfusion.
Client *eed +u':

Question 2
Type: MCSA
A patient has an estimated blood loss of two liters and has a mean arterial pressure ranging between 71 and ;1
mm8g. &f this patients hemodynamic status is not corrected$ the nurse realizes that which of the following can
occur
1. failure of sodium5potassium pump
2. cells will shrin!
. full and bounding peripheral pulses
!. metabolic al!alosis
Corre"t #ns$er: "
%ationale 1# 2ith a blood loss of two liters and a mean arterial pressure below @1 mm8g$ the body cells will
switch from aerobic to anaerobic metabolism. The lactic acid formed as a by5product of anaerobic metabolism
contributes to an acidotic state at the cellular level. Adenosine triphosphate$ the source of cellular energy$ is
produced inefficiently. +ac!ing energy$ the sodium5potassium pump fails. %otassium moves out of the cell$ while
sodium and water move inward.
%ationale 2# As this process continues$ the cells swell and not shrin!.
%ationale # %eripheral pulses may not be palpable.
%ationale !# The body develops acidosis and not al!alosis.
&lo'al %ationale: 2ith a blood loss of two liters and a mean arterial pressure below @1 mm8g$ the body cells
will switch from aerobic to anaerobic metabolism. The lactic acid formed as a by5product of anaerobic
metabolism contributes to an acidotic state at the cellular level. Adenosine triphosphate$ the source of cellular
energy$ is produced inefficiently. +ac!ing energy$ the sodium5potassium pump fails. %otassium moves out of the
cell$ while sodium and water move inward. As this process continues$ the cells swell and not shrin!. %eripheral
pulses may not be palpable. The body develops acidosis and not al!alosis.
Client *eed +u':

Question
Type: MCSA
The nurse$ caring for a patient who sustained a traumatic injury several days ago$ notes that the patient is
hypotensive$ oliguric$ and has cool$ pale s!in and acidosis. The nurse understands that these are manifestations of
which of the following
1. hypovolemic shoc!
2. cardiogenic shoc!
. septic shoc!
!. anaphylactic shoc!
Corre"t #ns$er: "
%ationale 1# 8ypovolemic shoc! is caused by a decrease in intravascular volume. &n hypovolemic shoc!$ the
venous blood returning to the heart decreases$ and ventricular fills drops. As a result$ stro!e volume$ cardiac
output$ and blood pressure decrease. 8ypovolemic shoc! affects all body systems.
%ationale 2# Cardiogenic shoc! occurs when the hearts pumping ability is compromised to the point that it
cannot maintain cardiac output and ade6uate tissue perfusion.
%ationale # %atients at ris! for developing infections leading to septic shoc! include those who are hospitalized$
have debilitating chronic illnesses$ or have poor nutritional status. Septic shoc! does not usually present with a
patient who presents with a traumatic injury.
%ationale !# Anaphylactic shoc! is the result of a widespread hypersensitivity reaction from medications$ blood
administration$ late4$ foods$ sna!e venom$ and insect stings.
&lo'al %ationale: 8ypovolemic shoc! is caused by a decrease in intravascular volume. &n hypovolemic shoc!$
the venous blood returning to the heart decreases$ and ventricular fills drops. As a result$ stro!e volume$ cardiac
output$ and blood pressure decrease. 8ypovolemic shoc! affects all body systems. Cardiogenic shoc! occurs
when the hearts pumping ability is compromised to the point that it cannot maintain cardiac output and ade6uate
tissue perfusion. %atients at ris! for developing infections leading to septic shoc! include those who are
hospitalized$ have debilitating chronic illnesses$ or have poor nutritional status. Septic shoc! does not usually
present with a patient who presents with a traumatic injury. Anaphylactic shoc! is the result of a widespread
hypersensitivity reaction from medications$ blood administration$ late4$ foods$ sna!e venom$ and insect stings.
Client *eed +u':
Learnin( -ut"o.e: B. (iscuss the ris! factors$ etiologies$ and pathophysiologies of hypovolemic shoc!$
cardiogenic shoc!$ obstructive shoc!$ and distributive shoc!.

Question !
Type: MCSA
The nurse suspects that a patient diagnosed with a myocardial infarction is developing cardiogenic shoc! when
which of the following is assessed
1. jugular vein distention
2. warm e4tremities
. laryngospasm
!. urticaria
Corre"t #ns$er: "
%ationale 1# Hugular vein distention is seen in cardiogenic shoc!.
%ationale 2# 2arm e4tremities are seen in early septic shoc! and anaphylactic shoc!.
%ationale # +aryngospasm is seen in anaphylactic shoc!.
%ationale !# ?rticaria is seen in anaphylactic shoc!.
&lo'al %ationale: Hugular vein distention is seen in cardiogenic shoc!. 2arm e4tremities are seen in early septic
shoc! and anaphylactic shoc!. +aryngospasm and urticaria are seen in anaphylactic shoc!.
Client *eed +u':

Question 5
Type: MCSA
A patient is diagnosed with a pneumothora4. The nurse realizes that unless this is treated$ the patient is at ris! for
developing which of the following types of shoc!
1. obstructive
2. hypovolemic
. cardiogenic
!. neurogenic
Corre"t #ns$er: "
%ationale 1# :bstructive shoc! is caused by an obstruction in the heart or great vessels that either impedes venous
return or prevents effective cardiac pumping action. :ne cause of obstructive shoc! is impaired diastolic filling as
seen in a pneumothora4.
%ationale 2# 8ypovolemic shoc! is seen in patients with a low circulating blood volume.
%ationale # Cardiogenic shoc! can occur in patients who have e4perienced a myocardial infarction.
%ationale !# 'eurogenic shoc! can occur in patients with spinal cord injuries.
&lo'al %ationale: :bstructive shoc! is caused by an obstruction in the heart or great vessels that either impedes
venous return or prevents effective cardiac pumping action. :ne cause of obstructive shoc! is impaired diastolic
filling as seen in a pneumothora4. 8ypovolemic shoc! is seen in patients with a low circulating blood volume.
Cardiogenic shoc! can occur in patients who have e4perienced a myocardial infarction. 'eurogenic shoc! can
occur in patients with spinal cord injuries.
Client *eed +u':

Question 2
Type: MCSA
An elderly patient is diagnosed with /. coli in the blood stream. &f not treated$ the nurse realizes this patient is at
ris! for developing which of the following types of shoc!
1. distributive
2. obstructive
. hypovolemic
!. anaphylactic
Corre"t #ns$er: "
%ationale 1# (istributive shoc! includes several types of shoc! that result from widespread vasodilatation and
decreased peripheral resistance. As the blood volume does not change$ relative hypovolemia results. :ne e4ample
of distributive shoc! is septic shoc!. Septic shoc! is one part of a progressive syndrome called systemic
inflammatory response syndrome and is most often the result of gram5negative bacterial infections such as /. coli.
%ationale 2# :bstructive shoc! is caused by an obstruction in the heart or great vessels that either impedes venous
return or prevents effective cardiac pumping action.
%ationale # 8ypovolemic shoc! occurs with a decrease in circulating blood volume.
%ationale !# Anaphylactic shoc! occurs as the result of a widespread humorally mediated hypersensitivity
reaction.
&lo'al %ationale: (istributive shoc! includes several types of shoc! that result from widespread vasodilatation
and decreased peripheral resistance. As the blood volume does not change$ relative hypovolemia results. :ne
e4ample of distributive shoc! is septic shoc!. Septic shoc! is one part of a progressive syndrome called systemic
inflammatory response syndrome and is most often the result of gram5negative bacterial infections such as /. coli.
:bstructive shoc! is caused by an obstruction in the heart or great vessels that either impedes venous return or
prevents effective cardiac pumping action. 8ypovolemic shoc! occurs with a decrease in circulating blood
volume. Anaphylactic shoc! occurs as the result of a widespread humorally mediated hypersensitivity reaction.
Client *eed +u':

Question 3
Type: MCSA
2hich of the following interventions would be essential for the nurse to assess first for a patient admitted with
severe facial injuries
1. signs of stridor$ cough$ or respiratory distress
2. blood pressure
. need for suctioning
!. mouth for loose teeth or obvious problems with the mouth
Corre"t #ns$er: "
%ationale 1# The patient with multiple injuries is at great ris! for developing airway obstruction and apnea. All of
the choices are important< however$ the most important intervention for the nurse to assess is to ma!e sure the
airway is patent and maintainable. The nurse should assess for manifestations of airway obstruction including
stridor$ tachypnea$ bradypnea$ cough$ cyanosis$ dyspnea$ decreased or absent breath sounds$ changes in o4ygen
levels$ and changes in level of consciousness.
%ationale 2# The blood pressure can be assessed after the patient is assessed for respiratory distress.
%ationale # The need for suctioning can be determined after it has been determined that the patient has an
ade6uate airway.
%ationale !# Assessment of the mouth can occur after determining that the patient has an ade6uate airway.
&lo'al %ationale: The patient with multiple injuries is at great ris! for developing airway obstruction and apnea.
All of the choices are important< however$ the most important intervention for the nurse to assess is to ma!e sure
the airway is patent and maintainable. The nurse should assess for manifestations of airway obstruction including
stridor$ tachypnea$ bradypnea$ cough$ cyanosis$ dyspnea$ decreased or absent breath sounds$ changes in o4ygen
levels$ and changes in level of consciousness. The blood pressure can be assessed after the patient is assessed for
respiratory distress. The need for suctioning can be determined after it has been determined that the patient has an
ade6uate airway. Assessment of the mouth can occur after determining that the patient has an ade6uate airway.
Client *eed +u':
Learnin( -ut"o.e: "1. ?se the nursing process as a framewor! for providing individualized care to patients
e4periencing trauma and shoc!.

Question 4
Type: MCSA
A patient who was a victim of rape si4 months ago comes to an outpatient clinic for the treatment of post5
traumatic stress disorder. 2hich data collected during the patients assessment would indicate a manifestation
associated with this disorder
1. discussed severe nightmares related to the traumatic event
2. denied anger or shoc!
. denied the need for drug or alcohol counseling
!. stated that her family is very supportive
Corre"t #ns$er: "
%ationale 1# %ost5traumatic stress disorder is an intense$ sustained emotional response to a disastrous event. &t is
characterized by emotions that range from anger to fear$ and by flashbac!s or psychic numbing. &n the initial
stage$ the patient can be calm or might e4press feelings of anger$ disbelief$ terror$ and shoc!. &n the long5term
phase$ which begins anywhere from a few days to several months after the event$ the patient often e4periences
flashbac!s and nightmares of the traumatic event. The patient also might call on ineffective coping mechanisms$
such as alcohol or drugs$ and withdraw from relationships.
%ationale 2# >eelings of anger and shoc! are associated with post5traumatic stress disorder.
%ationale # %atients who suffer from post5traumatic stress disorder are more prone to using alcohol or drugs.
%ationale !# These patients usually withdraw from relationships.
&lo'al %ationale: %ost5traumatic stress disorder is an intense$ sustained emotional response to a disastrous event.
&t is characterized by emotions that range from anger to fear$ and by flashbac!s or psychic numbing. &n the initial
stage$ the patient can be calm or might e4press feelings of anger$ disbelief$ terror$ and shoc!. &n the long5term
phase$ which begins anywhere from a few days to several months after the event$ the patient often e4periences
flashbac!s and nightmares of the traumatic event. The patient also might call on ineffective coping mechanisms$
such as alcohol or drugs$ and withdraw from relationships.
Client *eed +u':

Question 5
Type: MCSA
The nurse$ planning care for a patient diagnosed with shoc!$ would include which of the following interventions
for the nursing diagnosis of Anxiety
1. reduce stimuli and medicate for pain
2. assess blood pressure and heart rate.
. monitor central venous pressure
!. assess bowel sounds
Corre"t #ns$er: "
%ationale 1# &nterventions appropriate for the nursing diagnosis of Anxiety include reducing stimuli to crease
calm and facilitate rest and medicating for pain because pain precipitates or aggravates an4iety.
%ationale 2# Assessing blood pressure and heart rate would be appropriate for the nursing diagnosis of Decreased
Cardiac Output.
%ationale # Monitoring central venous pressure would be appropriate for the nursing diagnosis of Altered Tissue
Perfusion.
%ationale !# Assessing bowel sounds would be appropriate for the nursing diagnosis of Decreased Cardiac
Output.
&lo'al %ationale:
Client *eed +u':

Question !6
Type: MCSA
A patient hospitalized with traumatic injuries has the nursing diagnosis of Impaired Pysical Mo!ility. 2hich of
the following interventions would be appropriate for this patient
1. %rovide active range of motion e4ercises to affected e4tremities once every eight hours.
2. Turn and reposition every one hour.
. 3emove antiembolic stoc!ings for three hours every shift.
!. Administer tetanus to4oid.
Corre"t #ns$er: "
%ationale 1# The patient with traumatic injuries and the nursing diagnosis of Impaired Pysical Mo!ility should
have active range of motion e4ercises to the affected e4tremities once every eight hours.
%ationale 2# The patient should be turned and repositioned every two hours.
%ationale # Antiembolic stoc!ings should be removed for one hour every shift.
%ationale !# Administering the tetanus to4oid would be appropriate for the nursing diagnosis of "is# for
Infection.
&lo'al %ationale: The patient with traumatic injuries and the nursing diagnosis of Impaired Pysical Mo!ility
should have active range of motion e4ercises to the affected e4tremities once every eight hours. The patient
should be turned and repositioned every two hours. Antiembolic stoc!ings should be removed for one hour every
shift. Administering the tetanus to4oid would be appropriate for the nursing diagnosis of "is# for Infection.
Client *eed +u':

Question !1
Type: MCMA
A patient is admitted with trauma to the integumentary system. 2hich of the following are types of s!in trauma
1. cutaneous
2. abrasion
. laceration
!. contusion
Corre"t #ns$er: 0$7$;
%ationale 1# >our specific injuries to the integument are contusions$ abrasions$ puncture wounds$ and lacerations.
Cutaneous is a term used to refer to the integument. &t is not associated with trauma to the s!in.
%ationale 2# >our specific injuries to the integument are contusions$ abrasions$ puncture wounds$ and lacerations.
%ationale # >our specific injuries to the integument are contusions$ abrasions$ puncture wounds$ and lacerations.
%ationale !# >our specific injuries to the integument are contusions$ abrasions$ puncture wounds$ and lacerations.
&lo'al %ationale: >our specific injuries to the integument are contusions$ abrasions$ puncture wounds$ and
lacerations. Cutaneous is a term used to refer to the integument. &t is not associated with trauma to the s!in.
Client *eed +u':

Question !2
Type: MCMA
A trauma patient is being assessed with the Champion 3evised Scoring System. 2hat are the elements of this
scoring system
1. diastolic blood pressure
2. heart rate
. Ilasgow coma scale
!. systolic blood pressure
5. respiratory rate
Corre"t #ns$er: 7$;$.
%ationale 1# (iastolic blood pressure is not included in the Champion 3evised Scoring System.
%ationale 2# 8eart rate is not included in the Champion 3evised Scoring System.
%ationale # The Champion 3evised Scoring System analyzes three elements# the Ilasgow Coma Scale$ systolic
blood pressure$ and respiratory rate. The patient then receives a total score. The highest score is "0.
%ationale !# The Champion 3evised Scoring System analyzes three elements# the Ilasgow Coma Scale$ systolic
%ationale 5# The Champion 3evised Scoring System analyzes three elements# the Ilasgow Coma Scale$ systolic
&lo'al %ationale: The Champion 3evised Scoring System analyzes three elements# the Ilasgow Coma Scale$
systolic blood pressure$ and respiratory rate. The patient then receives a total score. The highest score is "0.
Although the diastolic blood pressure and heart rate are a part of the patients assessment$ they are not included in
the Champion 3evised Scoring System.
Client *eed +u':
Learnin( -ut"o.e: .. (iscuss diagnostic tests used in assessing patients e4periencing trauma.

Question !
Type: MC8S
A patient comes to the emergency department with bright red blood flowing from the lower right arm. %lace an
)J* over the artery used to control the bleeding.
Corre"t #ns$er:
%ationale # (irect pressure is applied over the artery supplying the lower arm. The radial artery is not appropriate
as it is in the lower arm and is affected by the trauma. 'o other arterial pressure point will control the bleeding of
the lower arm.
&lo'al %ationale:
Client *eed +u':

Question !!
Type: MC8S
(uring shoc!$ the reticuloendothelial Gupffer cells can be destroyed. %lace an )J* on the location of these cells.
Corre"t #ns$er:
%ationale # (uring shoc!$ the blood supply to the liver is impaired from constriction of the blood supply to the
liver. The Gupffer cells Cphagocytes that destroy bacteriaD are destroyed and bacteria can proliferate.
&lo'al %ationale:
Client *eed +u':

Question !5
Type: MCSA
&n reviewing the patient manifestations Csee aboveD$ the nurse recognizes the patient is in which stage of shoc!
1. compensated
2. mild
. moderate
!. severe
Corre"t #ns$er: 7
%ationale 1# 2ith compensated shoc!$ the blood loss is F.1 m+ with up to ".A blood loss. :ther indicators are
normal or increased$ the patient is only slightly an4ious.
%ationale 2# Mild shoc! has a blood loss of F.1K".11 m+$ ".AK71A blood volume loss$ heart rate L"11$ blood
pressure is normal$ the pulse pressure is decreased$ the capillary refill and respiratory rate are slightly increased$
urine output is 01K71 m+,h and the patient is mildly an4ious to agitated.
%ationale # The manifestations found in moderate shoc! are# blood loss of ".11K0111 m+$ 71AK;1A blood
loss$ the heart rate is L"01$ the blood pressure and pulse pressure are decreased$ capillary refill is increased over
the normal$ the patient has moderate tachypnea$ the urinary output is below normal$ and the mental status is
altered.
%ationale !# &n severe shoc!$ the patients condition has deteriorated mar!edly with over 0111 m+ blood loss and
L;1A loss of blood volume.
&lo'al %ationale:
Client *eed +u':

Question !2
Type: MCSA
A posttrauma patient has these laboratory results Csee aboveD. -ased on analyzing of the laboratory results$ the
nurse
1. suspects distributive shoc!.
2. recognizes the results as normal.
. places the patient in contact precautions.
!. prepares for insertion of a central venous catheter.
Corre"t #ns$er: 0
%ationale 1# (istributive shoc! would have a decrease in blood volume because of relative hypovolemia.
%ationale 2# All of the laboratory values are within normal limits. The 2-C ranges from . to "1 thousand$
neutrophils ..A5F1A$ monocytes 0A5=A$ eosinophils "A5;A$ and lymphocytes 01A5;1A.
%ationale # The patient does not have an infection.
%ationale !# A central venous catheter is not re6uired for this patient.
&lo'al %ationale: All of the laboratory values are within normal limits. The 2-C ranges from . to "1 thousand$
neutrophils ..A5F1A$ monocytes 0A5=A$ eosinophils "A5;A$ and lymphocytes 01A5;1A. (istributive shoc!
would have a decrease in blood volume because of relative hypovolemia< the patient does not have an infection$
therefore does not need contact precautions and a central venous catheter is not needed in this situation.
Client *eed +u':

Question !3
Type: >&-
A patient is to receive nitroglycerin CTridilD "1 mcg,min. The medication strength is .1 mg,0.1 m+. The &E rate
will be MMMMMMMMMMCfill in the blan!D.
+tandard Te/t:
Corre"t #ns$er: 7
%ationale # "1 mcg is changed to 1.1" mg by moving the decimal three places to the left. The problem is then
1.1" mg,min N 4 m+,h
1. 1" mg,min 4 @1,@1 N 1.@ mg,@1 min N 1.@ mg,"h
1. @ mg,h N 4m+,h
1. @ mg,4 m+ N .1 mg,0.1 m+
.1. N ".1
4 N 7
&lo'al %ationale:
Client *eed +u':
*ursin(/,nte(rated Con"epts: 'ursing %rocess# /valuation

Question !4
Type: MCMA
A patient has received ";. m+ of blood and complains of chills. The nurse will also assess for which of the
following
1. bradypnea
2. urticaria
. fever
!. hypertension
5. lumbar pain
Corre"t #ns$er: 0$7$.
%ationale 1# %atients who are having a hemolytic reaction to blood will e4perience dyspnea$ urticaria$ fever$
hypotension$ lumbar pain$ abdominal pain$ chills$ and nausea and vomiting. The patients respiratory rate will not
decrease.
hypotension$ lumbar pain$ abdominal pain$ chills$ and nausea and vomiting.
%ationale # %atients who are having a hemolytic reaction to blood will e4perience dyspnea$ urticaria$ fever$
%ationale !# %atients who are having a hemolytic reaction to blood will e4perience dyspnea$ urticaria$ fever$
hypotension$ lumbar pain$ abdominal pain$ chills$ and nausea and vomiting. Their blood pressure will not be
elevated.
&lo'al %ationale: %atients having a hemolytic reaction to blood will e4perience dyspnea$ urticaria$ fever$
hypotension$ lumbar pain$ abdominal pain$ chills$ and nausea and vomiting. Symptoms occur because of clumping
of the 3-Cs$ which bloc! capillaries and the action of macrophages engulfing the clumped 3-Cs. The activity of
the macrophages releases free hemoglobin. The patient will not have hypertension and will have tachypnea
instead of bradypnea.
Client *eed +u':

Question !5
Type: MCMA
A patient in hypovolemic shoc! is receiving a colloid solution Cplasma e4panderD. The rate of infusion is slowed
when the nurse assesses which of the following
1. a prothrombin time of "7.. seconds
2. jugular vein distension
. tenting of s!in
!. increased central venous pressure
5. auscultation of crac!les and wheezes
Corre"t #ns$er: 0$;$.
%ationale 1# A prothrombin time of "7.. seconds is within normal range.
%ationale 2# Hugular vein distension$ increased central venous pressure$ and crac!les and wheezes indicate
circulatory overload and pulmonary edema.
%ationale # Tenting of the s!in is associated with dehydration.
%ationale !# Hugular vein distension$ increased central venous pressure$ and crac!les and wheezes indicate
%ationale 5# Hugular vein distension$ increased central venous pressure$ and crac!les and wheezes indicate
&lo'al %ationale: Hugular vein distension$ increased central venous pressure$ and crac!les and wheezes indicate
circulatory overload and pulmonary edema. The rate of infusion would be slowed and the physician notified.
Tenting of s!in would indicate dehydration and the need for more fluid replacement.
Client *eed +u':

Question 56
Type: S/O
An on5the5scene rapid assessment is completed on the trauma victim. %lace the assessments in order of
importance.
+tandard Te/t: Clic! and drag the options below to move them up or down.
Choi"e 1. assessment for obvious injuries
Choi"e 2. Champion 3evised Trauma Scoring system
Choi"e . airway and breathing assessment
Choi"e !. circulation assessment
Choi"e 5. level of consciousness and pupillary function
Corre"t #ns$er: ;$.$"$0$7
%ationale 1# The fourth step is to assess for obvious injuries.
%ationale 2# The last step is use the Champion 3evised Trauma Scoring system.
%ationale # The first step is to assess the patients airway and breathing.
%ationale !# The second step is to assess the patients circulatory system.
%ationale 5# The third step is to assess the patients level of consciousness and pupillary function.
&lo'al %ationale: The airway and breathing assessment is completed first with the circulatory assessment second
as this follows the principle of the A-Cs. The airway must be patent with ade6uate breathing to provide o4ygen to
the vital organs. The level of consciousness and pupillary function will indicate any head injury,spinal cord injury
that must be immobilized before transport. The Champion 3evised Trauma Scoring system will indicate the
chance of survival for the trauma victim based on the Ilasgow Coma Scale$ systolic blood pressure$ and
respiratory rate.
Client *eed +u':


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LeMone/Burke/Bauldoff, Medical-Surgical Nursing 5th Edition Test Bank

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