Exam 2 Rotating Case Studies latest update 2023 questions
and answers with complete solution
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 abdomen, and initiation of
pulse oximetry are considered part of the secondary survey.
Which of the following signs and symptoms of increased ICP after head trauma
would appear first?
a.) Bradycardia
b.) Large amounts of very dilute urine
c.) Restlessness and confusion
d.) Widened pulse pressure
c.) Restlessness and confusion
Rationale:
The earliest symptom of elevated ICP is a change in mental status. Bradycardia,
widened pulse pressure, and bradypnea occur later. The client may void large amounts
of very dilute urine if there's damage to the posterior pituitary.
The nurse is caring for a client with a closed head injury. Which of the following
would contribute to intracrainal hypertension?
a.) hypoventilation
b.) elevating the head of the bed
c.) hypernatremia
d.) quiet darkened environnent
a.) hypoventilation
Rationale:
Hypoventilation leads to vasodilation and increased intracranial pressure.
A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry
mucous membranes. Which of the following nursing interventions is the most
appropriate to perform initially?
a.) Evaluate urine specific gravity
,b.) Anticipate treatment for renal failure
c.) Provide emollients to the skin to prevent breakdown
d.) Slow down the IV fluids and notify the physician
a.) Evaluate urine specific gravity
Rationale:
Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the
pituitary to produce anti-diuretic hormone. This may occur with increased intracranial
pressure and head trauma; the nurse evaluates for low urine specific gravity, increased
serum osmolarity, and dehydration. There's no evidence that the client is experiencing
renal failure. Providing emollients to prevent skin breakdown is important, but doesn't
need to be performed immediately. Slowing the rate of IV fluid would contribute to
dehydration when polyuria is present.
The client is admitted to the medical floor with a diagnosis of closed head injury.
Which nursing intervention has priority?
A) Assess neurological status.
B) Monitor pulse, respiration, and blood pressure.
C) Initiate an intravenous access.
D) Maintain an adequate airway.
D
The 29-year-old client that was employed as a forklift operator sustains a
traumatic brain injury secondary to a motor vehicle accident. The client is being
discharged from the rehabilitation unit after 3 months and has cognitive deficits.
Which goal would be more realistic for this client?
A) The client will return to work within 6 months.
B) The client is able to focus and stay on task for 10 minutes. C) The client will be
able to dress self without assistance.
D) The client will regain power and bladder control.
B
When planning the care of a client who is experiencing post-traumatic stress
disorder, the nurse identifies which of the following as an appropriate goal? The
client will report:
A) A decrease in flashbacks and nightmares.
B) A decrease in hearing voices.
C) Spending less time on ritualistic behavior.
D) Having more energy.
A
The nurse is talking with a client who just had a beautiful bouquet of roses
delivered. Suddenly the client becomes tearful and stares out the window. The
client has a history of sexual abuse. Which of the following should the nurse
include in the plan of care for this client?
A) Tell the client to relax and enjoy the roses
B) Tell the client that the sexual abuse was in the past
C) Give the client some alone time and return later
D) Assess if the client is having a flashback
D
, A nursing instructor is teaching about trauma and stressor-related disorders.
Which student statement indicates that further instruction is needed?
1. "The trauma that women experience is more likely to be sexual assault and
child sexual abuse."
2. "The trauma that men experience is more likely to be accidents, physical
assaults, combat, or viewing death or injury."
3. "After exposure to a traumatic event, only 10 percent of victims develop post-
traumatic stress disorder (PTSD)."
4. "Research shows that PTSD is more common in men than in women."
4
A nurse has been caring for a client diagnosed with PTSD. Which realistic goal
should be included in this client's plan of care?
1. The client will have no flashbacks.
2. The client will be able to feel a full range of emotions by discharge.
3. The client will not require zolpidem (Ambien) to obtain adequate sleep by
discharge.
4. The client will refrain from discussing the traumatic event.
3
A nurse is admitting a client who has been diagnosed with PTSD. Which of the
following symptoms might the nurse expect to assess? (Select all that apply.)
1. Feelings of guilt that precipitate social isolation
2. Aggressive behavior that affects job performance
3. Relationship problems
4. High levels of anxiety
5. Escalating symptoms lasting less than one month
1, 2, 3, 4
A family asks the nurse why their son was diagnosed with PTSD and others in the
accident were not. Which of the following information should the nurse offer?
(Select all that apply.)
1. An individual's religious affiliation can affect response to trauma.
2. Responses are affected by how an individual handled previous trauma.
3. Protectiveness of family and friends can help an individual deal with trauma.
4. Control over the possibility of recurrence can affect the response to trauma.
5. The time in which the trauma occurred can affect the individual's response.
2, 3, 4, 5
A nurse would recognize which of the following as the best predictors of PTSD in
Vietnam veterans? (Select all that apply.)
1. The severity of the stressor
2. The degree of ego strength
3. The degree of psychosocial isolation in the recovery environment
4. The attitudes of society regarding the experience
5. The presence of preexisting psychopathology
1, 3
A client who is a veteran of the Gulf War is being assessed by a nurse for post-
traumatic stress disorder (PTSD). Which of the following client symptoms would
support this diagnosis? (Select all that apply.)
and answers with complete solution
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 abdomen, and initiation of
pulse oximetry are considered part of the secondary survey.
Which of the following signs and symptoms of increased ICP after head trauma
would appear first?
a.) Bradycardia
b.) Large amounts of very dilute urine
c.) Restlessness and confusion
d.) Widened pulse pressure
c.) Restlessness and confusion
Rationale:
The earliest symptom of elevated ICP is a change in mental status. Bradycardia,
widened pulse pressure, and bradypnea occur later. The client may void large amounts
of very dilute urine if there's damage to the posterior pituitary.
The nurse is caring for a client with a closed head injury. Which of the following
would contribute to intracrainal hypertension?
a.) hypoventilation
b.) elevating the head of the bed
c.) hypernatremia
d.) quiet darkened environnent
a.) hypoventilation
Rationale:
Hypoventilation leads to vasodilation and increased intracranial pressure.
A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry
mucous membranes. Which of the following nursing interventions is the most
appropriate to perform initially?
a.) Evaluate urine specific gravity
,b.) Anticipate treatment for renal failure
c.) Provide emollients to the skin to prevent breakdown
d.) Slow down the IV fluids and notify the physician
a.) Evaluate urine specific gravity
Rationale:
Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the
pituitary to produce anti-diuretic hormone. This may occur with increased intracranial
pressure and head trauma; the nurse evaluates for low urine specific gravity, increased
serum osmolarity, and dehydration. There's no evidence that the client is experiencing
renal failure. Providing emollients to prevent skin breakdown is important, but doesn't
need to be performed immediately. Slowing the rate of IV fluid would contribute to
dehydration when polyuria is present.
The client is admitted to the medical floor with a diagnosis of closed head injury.
Which nursing intervention has priority?
A) Assess neurological status.
B) Monitor pulse, respiration, and blood pressure.
C) Initiate an intravenous access.
D) Maintain an adequate airway.
D
The 29-year-old client that was employed as a forklift operator sustains a
traumatic brain injury secondary to a motor vehicle accident. The client is being
discharged from the rehabilitation unit after 3 months and has cognitive deficits.
Which goal would be more realistic for this client?
A) The client will return to work within 6 months.
B) The client is able to focus and stay on task for 10 minutes. C) The client will be
able to dress self without assistance.
D) The client will regain power and bladder control.
B
When planning the care of a client who is experiencing post-traumatic stress
disorder, the nurse identifies which of the following as an appropriate goal? The
client will report:
A) A decrease in flashbacks and nightmares.
B) A decrease in hearing voices.
C) Spending less time on ritualistic behavior.
D) Having more energy.
A
The nurse is talking with a client who just had a beautiful bouquet of roses
delivered. Suddenly the client becomes tearful and stares out the window. The
client has a history of sexual abuse. Which of the following should the nurse
include in the plan of care for this client?
A) Tell the client to relax and enjoy the roses
B) Tell the client that the sexual abuse was in the past
C) Give the client some alone time and return later
D) Assess if the client is having a flashback
D
, A nursing instructor is teaching about trauma and stressor-related disorders.
Which student statement indicates that further instruction is needed?
1. "The trauma that women experience is more likely to be sexual assault and
child sexual abuse."
2. "The trauma that men experience is more likely to be accidents, physical
assaults, combat, or viewing death or injury."
3. "After exposure to a traumatic event, only 10 percent of victims develop post-
traumatic stress disorder (PTSD)."
4. "Research shows that PTSD is more common in men than in women."
4
A nurse has been caring for a client diagnosed with PTSD. Which realistic goal
should be included in this client's plan of care?
1. The client will have no flashbacks.
2. The client will be able to feel a full range of emotions by discharge.
3. The client will not require zolpidem (Ambien) to obtain adequate sleep by
discharge.
4. The client will refrain from discussing the traumatic event.
3
A nurse is admitting a client who has been diagnosed with PTSD. Which of the
following symptoms might the nurse expect to assess? (Select all that apply.)
1. Feelings of guilt that precipitate social isolation
2. Aggressive behavior that affects job performance
3. Relationship problems
4. High levels of anxiety
5. Escalating symptoms lasting less than one month
1, 2, 3, 4
A family asks the nurse why their son was diagnosed with PTSD and others in the
accident were not. Which of the following information should the nurse offer?
(Select all that apply.)
1. An individual's religious affiliation can affect response to trauma.
2. Responses are affected by how an individual handled previous trauma.
3. Protectiveness of family and friends can help an individual deal with trauma.
4. Control over the possibility of recurrence can affect the response to trauma.
5. The time in which the trauma occurred can affect the individual's response.
2, 3, 4, 5
A nurse would recognize which of the following as the best predictors of PTSD in
Vietnam veterans? (Select all that apply.)
1. The severity of the stressor
2. The degree of ego strength
3. The degree of psychosocial isolation in the recovery environment
4. The attitudes of society regarding the experience
5. The presence of preexisting psychopathology
1, 3
A client who is a veteran of the Gulf War is being assessed by a nurse for post-
traumatic stress disorder (PTSD). Which of the following client symptoms would
support this diagnosis? (Select all that apply.)
