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Trauma/SCI/TBI/ICP NCLEX Exam Questions with 100% Correct Answers $11.49   Add to cart

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Trauma/SCI/TBI/ICP NCLEX Exam Questions with 100% Correct Answers

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Trauma/SCI/TBI/ICP NCLEX Exam Questions with 100% Correct Answers You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients: a. An ambulatory, dazed 25-year-old male with a bandaged head woun...

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  • October 23, 2024
  • 33
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • Nclex
  • Nclex
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©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.

Trauma/SCI/TBI/ICP NCLEX Exam

Questions with 100% Correct Answers


You are working in the triage area of an ED, and four patients approach the

triage desk at the same time. List the order in which you will assess these

patients:



a. An ambulatory, dazed 25-year-old male with a bandaged head wound

b. An irritable infant with a fever, petechiae, and nuchal rigidity

c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no

deformity

d. A 50-year-old female with moderate abdominal pain and occasional

vomiting.



1.) A B D C

2.) B A D C

3.) C D B A

4.) C B A D - ✔✔2.) B A D C

,©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.


Rationale:

An irritable infant with fever and petechiae should be further assessed for

other meningeal signs. The patient with the head wound needs additional

history and assessment for intracranial pressure. The patient with moderate

abdominal pain is uncomfortable, but not unstable at this point. For the

ankle injury, medical evaluation can be delayed 24 - 48 hours if necessary.

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.) Complete set of vital signs

b.) Palpation and auscultation of the abdomen

c.) Brief neurologic assessment

d.) Initiation of pulse oximetry - ✔✔c.) Brief neurologic assessment



Rationale:

A brief neurologic assessment to determine level of consciousness and

pupil reaction is part of the primary survey. Vital signs, assessment of the

,©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.

abdomen, and initiation of pulse oximetry are considered part of the

secondary survey.

You respond to a call for help from the ED waiting room. There is an elderly

patient lying on the floor. List the order for the actions that you must

perform.



a. Perform the chin lift or jaw thrust maneuver.

b. Establish unresponsiveness.

c. Initiate cardiopulmonary resuscitation (CPR).

d. Call for help and activate the code team.

e. Instruct a nursing assistant to get the crash cart.



1.) A B C E D

2.) B D A C E

3.) C A B E D

4.) D C B E A

5.) E C D B A - ✔✔2.) B D A C E



Rationale:

, ©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.

Establish unresponsiveness first. (The patient may have fallen and

sustained a minor injury.) If the patient is unresponsive, get help and have

someone initiate the code. Performing the chin lift or jaw thrust maneuver

opens the airway. The nurse is then responsible for starting CPR. CPR

should not be interrupted until the patient recovers or it is determined that

heroic efforts have been exhausted. A crash cart should be at the site when

the code team arrives; however, basic CPR can be effectively performed

until the team arrives.

A client with trauma to the chest develops a tension pneumothorax. After a

needle thorocostomy is performed the nurse would expect:



a.) an increase in blood pressure.

b.) a decrease in blood pressure.

c.) an increase in jugular venous distension.

d.) a decrease in level of consciousness. - ✔✔a.) an increase in blood

pressure.



Rationale:

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