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Exam 3- Trauma Pearson (DETAILED ANSWERS) Semester 2 2024 - DISTINCTION_.pdf
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Exam 3- Trauma Pearson (DETAILED ANSWERS) Semester 2 2024 - DISTINCTION_.pdf
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8/11/24, 7:36 AMJeremiah
Exam 3- Trauma Pears 24 term
v6b
Terms in this set (97)
Which intervention is of highest priority in Washing hands before all client contact
preventing infections in a multiple trauma
victim? Rationale:
Hand washing before contact with a patient is the best way to prevent infection in a
hospitalized client. Assessment of temperature is assessment, not prevention. Providing
Assessment of temperature every 3-4 hours a diet high in protein promotes healing of wounds. Changing a dressing every shift also
promotes healing.
Providing a diet high in calories and protein
Changing the client's dressing every shift
Washing hands before all client contact
A client who is paralyzed from severe injuries Ineffective denial
sustained during an automobile accident
continually attempts to perform activities
beyond capabilities. Which is the most Rationale: The client is exhibiting signs of denial by failure to adjust to the limitations of
appropriate nursing diagnosis for this client? paralysis. The client may have anxiety and a disturbed body image, but the priority here
is the denial. The client is not at risk for trauma since that has already happened.
Disturbed image
Risk for trauma
Anxiety
Ineffective denial
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The nurse is caring for a client involved in a Surgery
motor vehicle crash that sustained an
intracranial hemorrhage. The client's Rationale:
condition is deteriorating and the nurse Intracranial pressure (ICP) will be monitored when a head injury is present, and if the
notes that the client's intracranial pressure is pressure rises to dangerous levels, surgery will be performed to release some of the
rising to dangerous levels. This assessment pressure. The client has an intracranial hemorrhage, therefore, administering a blood
finding would indicate that the physician is thinner would be contraindicated. While therapy and occupational therapy may be
considering which treatment? required for this client, it is not of immediate concern based on the findings.
Physical therapy
Occupational therapy
Surgery
A blood thinner
The nurse formulates a nursing diagnosis of Encourage the family to express feelings and ask questions.
ineffective family processes for the family of
a child who has sustained a brain injury Rationale:
during an automobile accident. The nurse is It is optimal to find out what the family's perception is of what is going on and what they
aware that when considering this nursing feel their needs are. The best way to do this is to encourage them to ask questions and
diagnosis which intervention has the highest express their feelings. While families may need teaching about seat belts and sources of
priority? support, now is not the optimal time to institute these interventions. Most pediatric
intensive care units have open visiting for the family.
Explain the visiting rules of the intensive care
unit.
Encourage the family to express feelings and
ask questions.
Teach the family the importance of using
seat belts.
Refer the family to supportive services in the
community.
The nurse is planning care for a client who Offer to call the family minister.
has sustained multiple injuries from a motor
vehicle crash. The nurse notes that the client Rationale:
and the client's family are experiencing When noticing a client or client's family in spiritual distress, it is appropriate to contact
spiritual distress. Which action taken by the the family minister or spiritual leader. It is not appropriate to encourage the family not
nurse would be most appropriate? to discuss the accident. The family and client should be encouraged to express their
feelings. For the nurse to assume and leave the client and family alone would be
Leave the client and family alone. inappropriate as it would be more appropriate for the nurse to remain present. While it
is appropriate to evaluate the needs at the home should the client be discharged, it is
Discuss with the family the difficulties they not appropriate to merely discuss with the family the difficulties they will face.
will experience when taking the client to the
home environment.
Encourage the family not to discuss the
accident with the client.
Offer to call the family minister.
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Severe facial injuries, such as those resulting Airway obstruction
from going through the windshield of a car,
increase the risk for all of the following. Rationale: The first priority is always the airway. Assessing the airway and initiating
Which would the nurse assess for first? interventions are the first steps in managing a client who has been in a motor vehicle
crash. Although checking for hemorrhage, contusions, and fractures is important, a
Airway obstruction patent airway is the number-one priority for survival.
Hemorrhage
Fractures
Contusions
Which finding indicates a positive outcome An oxygen saturation of 96% on 2L NC
in the treatment of a client who suffered
trauma injuries from a motor vehicle crash? Rationale: An oxygen saturation of 96% on 2L NC would be a desired outcome for a
client. A positive outcome for a client would be maintaining an oxygen saturation of
An oxygen saturation of 90% on room air greater than 95%; therefore an oxygen saturation of 90% on room air would not be a
desired outcome. It is also desired that the respiratory rate and pulse rate maintain
A respiratory rate of 36 within normal limits. The pulse rate of 140 and respiratory rate of 36 are not within
normal limits. .
An oxygen saturation of 96% on 2L NC
A pulse rate of 140
Which is the most significant assessment Ability to speak
finding in a client with major trauma
following a motor vehicle accident? Rationale:
Using the ABCs, the client's ability to speak indicates an open airway. While the other
O2 saturation options are important assessments, they are not directly indicative of the presence of a
patent airway.
Level of orientation
Pulse rate
Ability to speak
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The nurse is conducting a presentation at a Using a forward-facing belt-positioning booster seat for children over 40 lb. in the back
local school during a parent-teacher seat
association (PTA) meeting regarding
childhood safety. The nurse is asked a For children 4' 9close double quote" and taller, making sure that the lap belt fits low
question about enhancing car safety. Which and tight across the lap/upper thigh area and that the shoulder belt is snug across the
topics are appropriate for the nurse to share chest and shoulder
with the group? (Select all that apply.)
Rationale: Children over the age of 1 should be in a forward-facing seat. School-age
Using a forward-facing belt-positioning children should be secured in a car seat in the back seat. It is okay to use a forward-
booster seat for children over 40 lb. in the facing belt-positioning booster seat for children over 40 lb. in the back seat. Both lap
back seat and shoulder belts should always be used. For children 4' 9close double quote" and
taller, make sure that the lap belt fits low and tight across the lap/upper thigh area and
Placing children over the age of 1 in a rear- that the shoulder belt is snug across the chest and shoulder to avoid abdominal injuries.
facing seat
Securing the car seat in the front or back
seat as long as it is belted to the seat
Using either the lap or shoulder belt as long
as the seat feels and is secure
For children 4' 9close double quote" and
taller, making sure that the lap belt fits low
and tight across the lap/upper thigh area
and that the shoulder belt is snug across the
chest and shoulder
The nurse is providing care to a client who An ECG
received sternal injuries as the result of an
airbag deployment after a motor vehicle Rationale
crash (MVC). The client is currently The nurse would anticipate that this client would require an ECG to assess any heart
experiencing an abnormal heart rate. Which damage. An MRI or CT scan would not accurately diagnose cardiac issues in this client.
diagnostic test does the nurse anticipate for An EEG is used to assess brain injury that can occur during an MVC.
this client?
An MRI scan
An ECG
An EEG
A CT scan
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