Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking

for Collaborative Care, 6th Edition

Test Bank
Chapter 10: Concepts of Emergency and Trauma Nursing
Chapter 12: Concepts of Emergency and Disaster Awareness
MULTIPLE CHOICE
1.
A.
B.
C.
D.

Which is the most important goal of triage?

Assigning each client to the most appropriate treatment area
Giving priority of care to the most critically ill or injured clients
Providing a through assessment of the client
Obtaining a complete history of the clients past medical-surgical history

ANS: B
The concept of emergency department (ED) triage is based upon sorting clients into
priority levels depending on illness or injury severity. The key concept is that the most
serious clients who present to the ED receive the quickest evaluation and treatment.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and
Maintenance;
2.
A.
B.
C.
D.

What is a correct statement regarding the major role of the triage nurse?
Provide a through and comprehensive assessment of each client.
Be able to splint and perform minor procedures.
Perform rapid assessment to determine priority of care.
Provide psychological support to family members.

ANS: C
The triage nurse should perform a rapid assessment to determine triage priority. The
triage nurse should not be assigned tasks or have responsibilities to specific clients that
will draw him or her away from the triage area.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and
Maintenance;

3.
A.
B.
C.
D.

What is the primary survey?

Airway, breathing, circulation, head to toe assessment
Airway, breathing, circulation, neurologic assessment
Airway and cervical spine control, breathing, circulation, disability, exposure
Airway and cervical spine control, breathing, circulation, head to toe assessment

ANS: C
The primary survey for a trauma client organizes the approach to the client so that
life-threatening injuries are rapidly identified and managed. The primary survey is based
on the standard mnemonic ABC, with an added D and E. A, airway and cervical spine
control, B, breathing, C, circulation, D, disability, E, exposure.
DIF: Cognitive Level: Knowledge
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity
4. A 22-year-old male arrives at the ED following a motor vehicle collision. He is not
awake and is being bagged with a bag-valve-mask by paramedics. He has sustained
obvious injuries to his head and face as well as an open right femur fracture that is
bleeding profusely. What should the nurses initial intervention be?
A. Splint the right lower extremity to decrease blood loss.
B. Apply direct pressure to the open area on the right leg.
C. Assess for a patent airway.
D. Start two large-bore intravenous lines.
ANS: C
The highest priority intervention in the primary survey is to establish a patent airway.
Without an adequate airway to supply oxygen to the cells, a cerebral injury could
progress to anoxic brain death. After an airway is established, the resuscitation may
continue to B for breathing and C for circulation assessment.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

5.
A.
B.
C.
D.

What statement best describes the basic concept of mass causality triage?
The greatest good for the greatest amount of people
First come, first served
Women and children first
First priority to the most critical

ANS: A
Triage for a mass causality incident differs from civilian triage in that its main goal is
to provide the most effective care for the greatest number of people. Clients are classified
into one of four categories: emergent, urgent, nonurgent, or expected to die. Clients who
are classified as expected to die would not be assigned first priority in a mass causality
situation.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Health Promotion and Maintenance
6. A 67-year-old male presents to the ED complaining of chest pain. His heart rate is
120 beats/min, his blood pressure is 100/68 mm Hg, and his respiratory rate is 20
breaths/min. His is short of breath and diaphoretic. In a three-tiered triage model, how
should the nurse prioritize this client?
A. Emergent
B. Urgent
C. Nonurgent
D. Dormant
ANS: A
In a three-tiered triage model of emergent, urgent, and nonurgent, the client in the
emergent triage category has a condition that may pose an immediate threat to life or
limb and is given the highest priority. The urgent triage category is for clients who should
be treated quickly but who do not have an immediate threat to life if they are not. Clients
categorized as nonurgent generally can tolerate several hours of waiting time without a
significant risk of deterioration.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

7. Which of the following statements is true regarding critical incident stress debriefing
(CISD)?
A. CISD should not occur until several months have passed since the incident.
B. CISD consists of a group leader who is the main speaker.
C. CISD encourages group discussion.
D. CISD is limited to health care providers.
ANS: C
CISD is comprised of a team of specially trained individuals who come together quickly
to deal with the emotional needs of health team members who have participated in a
devastating or disturbing incident. Sessions generally last from 1 to 3 hours. CISD group
leaders encourage group discussion by asking a series of questions designed to make
everyone involved explain their part of the story and/or how the incident personally
affected them.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Evaluation
MSC: Client Needs Category: Psychosocial Integrity
8. Which of the following statements are true regarding post-traumatic stress disorder
(PTSD)?
A. Individuals suffering from PTSD may display physical manifestations.
B. Professional burnout is rare secondary to PTSD.
C. Critical incident stress management is the only method to deal with PTSD.
D. Manifestations of PTSD are purely psychological.
ANS: A
PTSD may occur in health care providers after an extremely emotional incident. It may
be manifested by multiple psychological and physical effects such as flashbacks,
avoidance, diminished interest in previously enjoyable events, detachment, and physical
manifestations including rapid heart rate and insomnia and other physiologic effects of
anxiety. Individuals suffering from PTSD may have difficulty in relating in their usual
way to family and friends and may ultimately experience professional burnout.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Evaluation
MSC: Client Needs Category: Psychosocial Integrity

OTHER
1. Which of the following interventions should be performed during the primary survey
for trauma? (Select all that apply.)
A. Removal of wet clothing
B.
Splinting of open fractures
C.
Initiating IV fluids
D.
Endotracheal intubation
E.
Foley catheterization
F.
Needle decompression
G.
Laceration repair
H.
Rectal examination
ANS:
A, C, D, F
Rationale: The primary survey for a trauma client organizes the approach to the client so
that life-threatening injuries are rapidly identified and managed. The primary survey is
based on the standard mnemonic ABC, with an added D and E. A, airway and cervical
spine control, B, breathing, C, circulation, D, disability, E, exposure. After completion of
the primary diagnostic studies, laboratory studies, and insertion of gastric and urinary
tubes, the secondary survey, a complete head to toe assessment can be carried out.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity
2. Choose the interventions that are appropriate under the primary survey. (Select all
that apply.)
A. Blood transfusion
B.
Insertion of a chest tube
C.
Endotracheal intubation
D.
Laceration repair
E.
Insertion of a nasogastric tube
ANS:
A, B, C
During the primary survey, life-threatening conditions are identified and managed
simultaneously. During the secondary survey, a complete head to toe assessment is
performed to identify and management any nonurgent injuries such as fractures and
lacerations.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step:
Implementation
MSC: Client Needs Category: Physiological Integrity