Exam 2 Rotating Case Studies UPDATED
Exam Questions and CORRECT Answers
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 - CORRECT ANSWER-✔✔ 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 - CORRECT ANSWER-✔✔ 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 - CORRECT ANSWER-✔✔ 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 - CORRECT ANSWER-✔✔ 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. - CORRECT ANSWER-✔✔ 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. - CORRECT ANSWER-✔✔ 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. - CORRECT ANSWER-✔✔ 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 - CORRECT ANSWER-✔✔ 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." - CORRECT
ANSWER-✔✔ 4
Exam Questions and CORRECT Answers
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 - CORRECT ANSWER-✔✔ 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 - CORRECT ANSWER-✔✔ 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 - CORRECT ANSWER-✔✔ 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 - CORRECT ANSWER-✔✔ 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. - CORRECT ANSWER-✔✔ 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. - CORRECT ANSWER-✔✔ 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. - CORRECT ANSWER-✔✔ 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 - CORRECT ANSWER-✔✔ 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." - CORRECT
ANSWER-✔✔ 4
