1.
A client was brought to the emergency
department after suffering a closed head injury
and lacerations around the face due to a hit-run
accident. The client is unconscious and has
minimal response to noxious stimuli. Which of
the following assessment findings if observed
after few hours, should be reported to the
physician immediately?
A. Bleeding around the lacerations.
B. Withdrawal of the client in response to painful
stimuli.
C. Bruises and minimal edema of the eyelids.
D. Drainage of a clear fluid from the client's nose.
Rationale: D. Drainage of a clear fluid from the
client’s nose.
Clear drainage from the client’s nose indicates
that there is a leakage of CSF and should be
reported to the physician immediately.
2. A nurse is providing discharge instruction to
a woman who has been treated for contusions
and bruises due to a domestic violence. What is
the priority intervention for this client?
A. Making a referral to a counselor.
B. Making an appointment to follow up on the
injuries.
C. Advising the client about contacting the
police.
D. Arranging transportation to a safe house.
Rationale: D. Arranging transportation to a safe
house.
Safety is a priority for this client and she should
not return to a place where violence could recur.
3. A client was brought to the ED due to an
abdominal trauma caused by a motorcycle
accident. During the assessment, the client
complains of epigastric pain and back pain.
Which of the following is true regarding the
diagnosis of pancreatic injury?
A. Redness and bruising may indicate the site of
the injury in blunt trauma.
B. The client is symptom-free during the early
post-injury period.
C. Signs of peritoneal irritation may indicate
pancreatic injury.
D. All of the above.
Rationale: D. All of the above
Blunt injury resulting from vehicular accidents
could cause pancreatic injury. Redness, bruising
in the flank and severe peritoneal irritation
are signs of a pancreatic injury. The client is
usually pain-free during the early post-injury
period; hence a comprehensive assessment and
monitoring should be done.
5. A 20-year-old male client was brought to the
emergency department with a gunshot wound
to the chest. In obtaining a history of the
incident to determine possible injuries, the
nurse should ask which of the following?
A. “What was the initial first aid done?”
B. “Where did the incident happen?”
C. “What direction did the bullet enter into the
body?”
D. “How long ago did the incident occur?”
Rationale: C. “What direction did the bullet enter
into the body?”
The entry point and direction of the bullet will
predict the involve injuries of the client.
6. When attending a client with a head and neck
trauma following a vehicular accident, the
nurse’s initial action is to?
A. Do oral and nasal suctioning.
B. Provide oxygen therapy.
C. Initiate intravenous access.
D. Immobilize the cervical area.
Rationale: D. Immobilize the cervical area.
Clients with suspected or possible cervical spine
injury must have their neck immobilized until
formal assessment occurs.
7. A client arrives at the emergency department
who suffered multiple injuries from a head-on
car collision. Which of the following assessment
should take the highest priority to take?
A. Irregular pulse.
B. Ecchymosis in the flank area.
C. A deviated trachea.
D. Unequal pupils.
Rationale: C. A deviated trachea.
A deviated trachea is a symptom of
tension pneumothorax, which will result in
respiratory distress if left untreated.
8. A female client is admitted in a disoriented
and restless state after sustaining a concussion
during a car accident. Which nursing
diagnosis takes highest priority for this client’s
plan of care?
A. Disturbed sensory perception (visual)
B. Self-care deficient: Dressing/grooming
C. Impaired verbal communication
D. Risk for injury
Rationale: D. Risk for injury
Because the client is disoriented and restless, the
most important nursing diagnosis is risk for
injury.
9. A female client has clear fluid leaking from
the nose following a basilar skull fracture. The
nurse assesses that this is cerebrospinal fluid if
the fluid:
A. Is clear and tests negative for glucose
B. Is grossly bloody in appearance and has a pH
of 6
C. Clumps together on the dressing and has a
pH of 7
D. Separates into concentric rings and test
positive of glucose
Rationale: D. Separates into concentric rings and
test positive of glucose
Leakage of cerebrospinal fluid (CSF) from the
ears or nose may accompany basilar skull
fracture. CSF can be distinguished from other
body fluids because the drainage will separate
into bloody and yellow concentric rings on
dressing material, called a halo sign. The fluid
also tests positive for glucose.
10. The nurse is caring for the male client who
begins to experience seizure activity while in
bed. Which of the following actions by the
nurse would be contraindicated?
A. Loosening restrictive clothing
B. Restraining the client’s limbs
C. Removing the pillow and raising padded side
rails
D. Positioning the client to side, if possible, with
the head flexed forward.
Rationale: B. Restraining the client’s limbs
The limbs are never restrained because the
strong muscle contractions could cause the client
harm. If the client is not in bed when seizure
activity begins, the nurse lowers the client to the
floor, if possible, protects the head from injury,
and moves furniture that may injure the client.
Other aspects of care are as described for the
client who is in bed.
1. Regular oral hygiene is an essential
intervention for the client who has had a stroke.
Which of the following nursing measures is
inappropriate when providing oral hygiene?
A. Placing the client on the back with a small
pillow under the head.
B. Keeping portable suctioning equipment at
the bedside.
C. Opening the client’s mouth with a padded
tongue blade.
D. Cleaning the client’s mouth and teeth with a
toothbrush.
Rationale: A. Placing the client on the back with
a small pillow under the head.
A helpless client should be positioned on the
side, not on the back. This lateral position helps
secretions escape from the throat and mouth,
minimizing the risk of aspiration.
2. A 78-year-old client is admitted to the
emergency department with numbness and
weakness of the left arm and slurred speech.
Which nursing intervention is a priority?
A. Prepare to administer recombinant tissue
plasminogen activator (rt-PA).
B. Discuss the precipitating factors that caused
the symptoms.
C. Schedule for A STAT computer tomography
(CT) scan of the head.
D. Notify the speech pathologist for an
emergency consult.
Rationale: C. Schedule for A STAT computer
tomography (CT) scan of the head.
A CT scan will determine if the client is having a
stroke or has a brain tumor or another
neurological disorder. This would also determine
if it is a hemorrhagic or ischemic accident and
guide the treatment because only an ischemic
stroke can use rt-PA. This would make (1) not the
priority since if a stroke was determined to be
hemorrhagic, rt-PA is contraindicated.
3. A client arrives in the emergency department
with an ischemic stroke and receives tissue
plasminogen activator (t-PA) administration.
Which is the priority nursing assessment?
A. Current medications.
B. Complete physical and history.
C. Time of onset of current stroke.
D. Upcoming surgical procedures.
Rationale: C. Time of onset of current stroke
The time of onset of a stroke to t-PA
administration is critical. Administration within 3
hours has better outcomes.
4. The nurse is caring for the client with
increased intracranial pressure. The nurse
would note which of the following trends in
vital signs if the ICP is rising?
A. Increasing temperature, increasing pulse,
increasing respirations, decreasing blood
pressure.
B. Increasing temperature, decreasing pulse,
decreasing respirations, increasing blood
pressure.
C. Decreasing temperature, decreasing pulse,
increasing respirations, decreasing blood
pressure.
D. Decreasing temperature, increasing pulse,
decreasing respirations, increasing blood
pressure.
Rationale: B. Increasing temperature,
decreasing pulse, decreasing respirations,
increasing blood pressure.
A change in vital signs may be a late sign of
increased intracranial pressure. Trends include
increasing temperature and blood pressure and
decreasing pulse and respirations. Respiratory
irregularities also may arise.
5. A client admitted to the hospital with a
subarachnoid hemorrhage has complaints of
severe headache, nuchal rigidity, and
projectile vomiting. The nurse knows lumbar
puncture (LP) would be contraindicated in this
client in which of the following circumstances?
A. Vomiting continues
B. Intracranial pressure (ICP) is increased
C. The client needs mechanical ventilation
D. Blood is anticipated in the cerebrospinal
fluid (CSF)
Rationale: B. Intracranial pressure (ICP) is
increased
Sudden removal of CSF results in pressures lower
in the lumbar area than the brain and favors
herniation of the brain; therefore, LP is
contraindicated with increased ICP.
6. An anxious female client complains of chest
tightness, tingling sensations, and palpitations.
Deep, rapid breathing, and carpal spasms are
noted. Which of the following priority action
should the nurse do first?
A. Provide oxygen therapy.
B. Notify the physician immediately.
C. Administer anxiolytic medication as ordered.
D. Have the client breathe into a brown paper
bag.
Rationale: D. Have the client breathe into a
brown paper bag.
The client is suffering from hyperventilation
secondary from anxiety, the initial action is to let
the client breathe in a paper bag that will allow
the rebreathing of carbon dioxide.
7. A nurse is providing discharge instruction to
a woman who has been treated for contusions
and bruises due to a domestic violence. What is
the priority intervention for this client?
A. Making a referral to a counselor.
B. Making an appointment to follow up on the
injuries.
C. Advising the client about contacting the
police.
D. Arranging transportation to a safe house.
Rationale: D. Arranging transportation to a safe
house.
Safety is a priority for this client and she should
not return to a place where violence could recur.
8. A white female client is admitted to an acute
care facility with a diagnosis of cerebrovascular
accident (CVA). Her history reveals bronchial
asthma exogenous obesity, and iron
deficiency anemia. Which history finding is a
risk factor for CVA?
A. Caucasian race
B. Female sex
C. Obesity
D. Bronchial asthma
Rationale: C. Obesity
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.