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1.

A client was brought to the emergency Blunt injury resulting from vehicular accidents
department after suffering a closed head injury could cause pancreatic injury. Redness, bruising
and lacerations around the face due to a hit-run in the flank and severe peritoneal irritation
accident. The client is unconscious and has are signs of a pancreatic injury. The client is
minimal response to noxious stimuli. Which of usually pain-free during the early post-injury
the following assessment findings if observed period; hence a comprehensive assessment and
after few hours, should be reported to the monitoring should be done.
physician immediately?
A. Bleeding around the lacerations. 5. A 20-year-old male client was brought to the
B. Withdrawal of the client in response to painful emergency department with a gunshot wound
stimuli. to the chest. In obtaining a history of the
C. Bruises and minimal edema of the eyelids. incident to determine possible injuries, the
D. Drainage of a clear fluid from the client's nose. nurse should ask which of the following?
A. “What was the initial first aid done?”
Rationale: D. Drainage of a clear fluid from the B. “Where did the incident happen?”
client’s nose. C. “What direction did the bullet enter into the
Clear drainage from the client’s nose indicates body?”
that there is a leakage of CSF and should be
D. “How long ago did the incident occur?”
reported to the physician immediately.

2. A nurse is providing discharge instruction to Rationale: C. “What direction did the bullet enter
a woman who has been treated for contusions into the body?”
and bruises due to a domestic violence. What is The entry point and direction of the bullet will
the priority intervention for this client? predict the involve injuries of the client.
A. Making a referral to a counselor.
6. When attending a client with a head and neck
B. Making an appointment to follow up on the
trauma following a vehicular accident, the
injuries.
nurse’s initial action is to?
C. Advising the client about contacting the
A. Do oral and nasal suctioning.
police.
B. Provide oxygen therapy.
D. Arranging transportation to a safe house.
C. Initiate intravenous access.
D. Immobilize the cervical area.
Rationale: D. Arranging transportation to a safe
house.
Safety is a priority for this client and she should Rationale: D. Immobilize the cervical area.
not return to a place where violence could recur. Clients with suspected or possible cervical spine
injury must have their neck immobilized until
3. A client was brought to the ED due to an formal assessment occurs.
abdominal trauma caused by a motorcycle
accident. During the assessment, the client 7. A client arrives at the emergency department
complains of epigastric pain and back pain. who suffered multiple injuries from a head-on
Which of the following is true regarding the car collision. Which of the following assessment
diagnosis of pancreatic injury? should take the highest priority to take?
A. Redness and bruising may indicate the site of A. Irregular pulse.
the injury in blunt trauma. B. Ecchymosis in the flank area.
B. The client is symptom-free during the early C. A deviated trachea.
post-injury period. D. Unequal pupils.
C. Signs of peritoneal irritation may indicate
pancreatic injury. Rationale: C. A deviated trachea.
D. All of the above. A deviated trachea is a symptom of
tension pneumothorax, which will result in
Rationale: D. All of the above respiratory distress if left untreated.
8. A female client is admitted in a disoriented floor, if possible, protects the head from injury,
and restless state after sustaining a concussion and moves furniture that may injure the client.
during a car accident. Which nursing Other aspects of care are as described for the
client who is in bed.
diagnosis takes highest priority for this client’s
plan of care? 1. Regular oral hygiene is an essential
A. Disturbed sensory perception (visual) intervention for the client who has had a stroke.
B. Self-care deficient: Dressing/grooming Which of the following nursing measures is
C. Impaired verbal communication inappropriate when providing oral hygiene?
D. Risk for injury A. Placing the client on the back with a small
pillow under the head.
Rationale: D. Risk for injury B. Keeping portable suctioning equipment at
Because the client is disoriented and restless, the
the bedside.
most important nursing diagnosis is risk for
injury. C. Opening the client’s mouth with a padded
tongue blade.
9. A female client has clear fluid leaking from D. Cleaning the client’s mouth and teeth with a
the nose following a basilar skull fracture. The toothbrush.
nurse assesses that this is cerebrospinal fluid if
the fluid: Rationale: A. Placing the client on the back with
A. Is clear and tests negative for glucose a small pillow under the head.
B. Is grossly bloody in appearance and has a pH A helpless client should be positioned on the
of 6 side, not on the back. This lateral position helps
C. Clumps together on the dressing and has a secretions escape from the throat and mouth,
pH of 7 minimizing the risk of aspiration.
D. Separates into concentric rings and test
positive of glucose 2. A 78-year-old client is admitted to the
emergency department with numbness and
Rationale: D. Separates into concentric rings and weakness of the left arm and slurred speech.
test positive of glucose Which nursing intervention is a priority?
Leakage of cerebrospinal fluid (CSF) from the A. Prepare to administer recombinant tissue
ears or nose may accompany basilar skull
plasminogen activator (rt-PA).
fracture. CSF can be distinguished from other
body fluids because the drainage will separate B. Discuss the precipitating factors that caused
into bloody and yellow concentric rings on the symptoms.
dressing material, called a halo sign. The fluid C. Schedule for A STAT computer tomography
also tests positive for glucose. (CT) scan of the head.
D. Notify the speech pathologist for an
10. The nurse is caring for the male client who emergency consult.
begins to experience seizure activity while in
bed. Which of the following actions by the Rationale: C. Schedule for A STAT computer
nurse would be contraindicated? tomography (CT) scan of the head.
A. Loosening restrictive clothing A CT scan will determine if the client is having a
B. Restraining the client’s limbs stroke or has a brain tumor or another
C. Removing the pillow and raising padded side neurological disorder. This would also determine
rails if it is a hemorrhagic or ischemic accident and
D. Positioning the client to side, if possible, with guide the treatment because only an ischemic
the head flexed forward. stroke can use rt-PA. This would make (1) not the
priority since if a stroke was determined to be
Rationale: B. Restraining the client’s limbs hemorrhagic, rt-PA is contraindicated.
The limbs are never restrained because the
strong muscle contractions could cause the client 3. A client arrives in the emergency department
harm. If the client is not in bed when seizure
with an ischemic stroke and receives tissue
activity begins, the nurse lowers the client to the
plasminogen activator (t-PA) administration. Sudden removal of CSF results in pressures lower
Which is the priority nursing assessment? in the lumbar area than the brain and favors
A. Current medications. herniation of the brain; therefore, LP is
contraindicated with increased ICP.
B. Complete physical and history.
C. Time of onset of current stroke.
D. Upcoming surgical procedures.
6. An anxious female client complains of chest
tightness, tingling sensations, and palpitations.
Rationale: C. Time of onset of current stroke
Deep, rapid breathing, and carpal spasms are
The time of onset of a stroke to t-PA
noted. Which of the following priority action
administration is critical. Administration within 3
should the nurse do first?
hours has better outcomes.
A. Provide oxygen therapy.
B. Notify the physician immediately.
4. The nurse is caring for the client with
C. Administer anxiolytic medication as ordered.
increased intracranial pressure. The nurse
D. Have the client breathe into a brown paper
would note which of the following trends in
bag.
vital signs if the ICP is rising?
A. Increasing temperature, increasing pulse,
Rationale: D. Have the client breathe into a
increasing respirations, decreasing blood brown paper bag.
pressure. The client is suffering from hyperventilation
B. Increasing temperature, decreasing pulse, secondary from anxiety, the initial action is to let
decreasing respirations, increasing blood the client breathe in a paper bag that will allow
pressure. the rebreathing of carbon dioxide.
C. Decreasing temperature, decreasing pulse,
increasing respirations, decreasing blood 7. A nurse is providing discharge instruction to
pressure. a woman who has been treated for contusions
D. Decreasing temperature, increasing pulse, and bruises due to a domestic violence. What is
decreasing respirations, increasing blood the priority intervention for this client?
pressure. A. Making a referral to a counselor.
B. Making an appointment to follow up on the
Rationale: B. Increasing temperature, injuries.
decreasing pulse, decreasing respirations, C. Advising the client about contacting the
increasing blood pressure. police.
A change in vital signs may be a late sign of D. Arranging transportation to a safe house.
increased intracranial pressure. Trends include
increasing temperature and blood pressure and Rationale: D. Arranging transportation to a safe
decreasing pulse and respirations. Respiratory house.
irregularities also may arise. Safety is a priority for this client and she should
not return to a place where violence could recur.
5. A client admitted to the hospital with a
subarachnoid hemorrhage has complaints of 8. A white female client is admitted to an acute
severe headache, nuchal rigidity, and care facility with a diagnosis of cerebrovascular
projectile vomiting. The nurse knows lumbar accident (CVA). Her history reveals bronchial
puncture (LP) would be contraindicated in this asthma exogenous obesity, and iron
client in which of the following circumstances? deficiency anemia. Which history finding is a
A. Vomiting continues risk factor for CVA?
B. Intracranial pressure (ICP) is increased A. Caucasian race
C. The client needs mechanical ventilation B. Female sex
D. Blood is anticipated in the cerebrospinal C. Obesity
fluid (CSF) D. Bronchial asthma

Rationale: B. Intracranial pressure (ICP) is Rationale: C. Obesity


increased
Obesity is a risk factor for CVA. Other risk factors
include a history of ischemic episodes,
cardiovascular disease, diabetes mellitus,
hypertension, polycythemia, smoking, oral
contraceptive use, emotional stress, family
history of CVA and advancing age.

9. The nurse is assigned to care for a female


client with complete right-sided hemiparesis.
The nurse plans care knowing that this
condition:
A. The client has completed bilateral paralysis of
the arms and legs.
B. The client has weakness on the right side of
the body, including the face and tongue.
C. The client has lost the ability to move the
right arm but can walk independently.
D. The client has lost the ability to move the
right arm but can walk independently.

Rationale: B. The client has weakness on the


right side of the body, including the face and
tongue.
Hemiparesis is a weakness of one side of the body
that may occur after a stroke. Complete
hemiparesis is a weakness of the face and
tongue, arm, and leg on one side. Complete
bilateral paralysis does not occur in this
condition.

10. In conducting a primary survey on a trauma


patient, which of the following is considered
one of the priority elements of the primary
survey?
A. Initiation of pulse oximetry.
B. Complete set of vital signs.
C. Client’s allergy history.
D. Brief neurologic assessment

Rationale: D. Brief neurologic assessment.


A brief neurologic assessment to determine the
level of consciousness and pupil reaction is part
of the primary survey. Vital signs, client’s allergy,
and initiation of pulse oximetry are considered
part of the secondary survey.