Chapter 45, Care of Patients with Emergent Conditions, Trauma, and Shock: Accidents, Psychological/Social Emergencies, and Emergency Care

Question 1 of 10

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Which action is the priority for a teenager who dives head first into the water and seconds later is observed floating facedown in the water?

• • Waiting to see if the victim moves spontaneouslyEarly intervention makes a critical difference in the survival of drowning victims; the nurse would not wait to observe movement.
• • Pulling the victim to safety and assessing airway patencyThe nurse would stabilize the neck and turn the patient on their back. The airway would be assessed. However, these would not be the first priority.
• • Stabilizing the neck and turning the victim on their backIf not breathing, the victim would be moved carefully to a flat surface and cardiopulmonary resuscitation would be started, but this would not be the priority.
• Correct
  • Instructing someone to call 911 emergency medical services (EMS)The nurse would first instruct someone to call EMS.

Question 2 of 10

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Which action would the nurse take immediately upon discovering an unknown, unconscious person with circumoral cyanosis, respiratory distress, and a palpable pulse?

• Correct
  • Perform a jaw-thrust maneuver.Because the nurse does not know the cause of unconsciousness or the extent of the injury, the nurse would perform the jaw-thrust maneuver to open the airway and protect the spine. If there are no respirations but a palpable pulse is present, an airway obstruction by the tongue would be suspected.
• • Perform a head tilt–chin lift maneuver.The head tilt–chin lift maneuver is used in the absence of spinal injury.
• • Roll the person to the recovery position.The nurse would not roll the person to the recovery position.
• • Perform a finger sweep to clear the airway.A blind finger sweep would never be performed because of the risk for forcing an object further into the airway.

Question 3 of 10

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The nurse is providing discharge information to a patient about home safety. Which patient statement indicates an understanding of the teaching?

• • “I will keep my water heater set at 125 degrees.”The patient should be instructed to maintain the water heater set at 120°F (48.8°C) or lower.
• • “I only need to have a smoke detector in the bedroom.”Smoke detectors and carbon monoxide alarms should be placed in several locations in the home to detect fire and carbon monoxide leaks.
• Correct
  • “I will make sure to place rubber mats underneath all of my rugs.”Rubber safety mats should be placed under all rugs to prevent slipping and potential injury.
• • “It is fine to smoke in bed as long as I am sure the cigarette is completely out before I fall asleep.”Patients should be instructed never to smoke in bed because this greatly increases the risk for house fires and injury.

Question 4 of 10

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Which intervention is appropriate for the nurse to take when providing first aid at the scene of a car accident? Select all that apply. One, some, or all responses may be correct.

• Correct
  • Look for a medical alert bracelet.The nurse would look for medical alert bracelets or necklaces, which could help determine next steps for treatment.
• • Remove any penetrating objects.The nurse would not remove penetrating objects because this can increase damage and bleeding.
• • Administer oral pain medication.The nurse would not administer oral medication because this can result in aspiration and compromised breathing.
• Correct
  • Use a calm tone and explain what is being done.The nurse would use a calm tone and explain what they are doing. Maintaining a sense of calm can decrease patient anxiety and improve outcomes.
• Correct
  • Briefly check on each victim before beginning care.The nurse would briefly check on each victim to triage and determine which patient should be taken care of first based on the acuteness of their injuries.

Question 5 of 10

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Which nursing intervention is appropriate when assessing a patient in the emergency department after a diving accident?

• • Elevate injured extremities.Elevation of an injured extremity is no longer recommended for preventing hemorrhage.
• • Tilt patient’s head to the side.The patient’s head should not be tilted, which could cause hyperextension of the neck. The nurse would immobilize the patient’s cervical spine immediately to prevent further damage.
• • Leave all clothing on and intact.The nurse would remove the patient’s clothing to check for other injuries.
• Correct
  • Note response to verbal stimuli.The nurse would note the patient’s response to verbal stimuli to assess neurological status.

Question 6 of 10

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Which nursing action is the priority when caring for a patient brought to the emergency department after a motor vehicle accident?

• • Feel for a carotid artery pulse.Though it is important for the nurse to check for a pulse, this is not the priority action based on the ABCDE mode of assessment.
• Correct
  • Assess for signs of breathing.Airway and breathing are priority assessments, so the priority action for the nurse is to assess the patient’s breathing pattern and intervene as needed.
• • Note response to verbal stimuli.It is important for the nurse to assess the patient’s response to verbal stimuli because this indicates their neurological status, but this is not the priority intervention.
• • Obtain a thorough patient history.A thorough patient history should be obtained after the nurse has determined the patient is stable.

Question 7 of 10

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Which patient situation would warrant the use of spinal motion restriction (SMR) precautions?

• • Older adult with kyphosisUse of SMR is contraindicated in older adult patients, especially those with kyphosis.
• • Patient who is awake, alert, and talkingPatients who are alert, awake, conversant, and without significant distracting injury or intoxication do not require spinal precautions.
• Correct
  • Unconsciousness from a fall off a ladderSMR should be used on patients with suspected spinal injury, such as from a fall resulting in loss of consciousness, until spinal injury can be ruled out.
• • Penetrating trauma from motor vehicle accidentSMR should not be used in patients with penetrating trauma injuries.

Question 8 of 10

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Which treatment would the nurse anticipate for a patient who presents to the emergency department with flail chest from a gunshot wound?

• • Application of a rib binderRib binding is not used as a treatment because it impairs the ability to take deep breaths, which can cause atelectasis and pneumonia.
• • Administration of nonsteroidal antiinflammatory drugs (NSAIDs)NSAIDs are indicated in the treatment of rib fractures, but flail chest is more painful and typically requires use of sedatives and stronger pain medications.
• • Placing the patient in supine positionThe patient is positioned on the affected side, not supine, because the ground or bed will act as a splint and reduce the pain of breathing.
• Correct
  • Intubation and mechanical ventilationIntubation and mechanical ventilation is often indicated for patients with flail chest until they are stabilized, so the nurse would anticipate this intervention and have supplies prepared at the bedside.

Question 9 of 10

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Which complication would the nurse suspect if auscultation of the heart and lungs reveals muffled heart tones?

• • PneumoniaPneumonia may be suspected with symptoms such as crackles in the lungs or green sputum, not muffled heart tones.
• • PneumothoraxPneumothorax is suspected with labored, shallow respirations, not muffled heart tones.
• Correct
  • Cardiac tamponadeHeart sounds become muffled with cardiac tamponade because blood collects in the pericardial sac, which compresses the myocardium and does not allow the heart to contract effectively.
• • Myocardial infarctionA sign of myocardial infarction is chest pain, not muffled heart tones.

Question 10 of 10

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Which intervention would the nurse anticipate for a patient with a stab wound to the abdomen? Select all that apply. One, some, or all responses may be correct.

• Correct
  • Taking patient for a computed tomography (CT) scanCT scan and sonography are often used to determine the extent of intraabdominal bleeding.
• Correct
  • Monitoring closely for Grey Turner signThe nurse would monitor closely for Grey Turner sign as this can indicate intraabdominal bleeding.
• Correct
  • Checking hemoglobin and hematocritThe nurse would monitor hemoglobin and hematocrit to determine the extent of blood loss and the need for administration of blood products.
• • Preparing patient for immediate surgeryNot all patients with abdominal trauma require immediate surgery.
• • Removing the penetrating object immediatelyPenetrating objects are removed with care, and they should not be removed too quickly or without oversight from the provider. It is better to leave the object in place until the provider or surgeon can determine the best way to remove it.