Chapter 67: Emergency Nursing
Hinkle: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th Edition
MULTIPLE CHOICE
1. Which client should the nurse prioritize as needing emergent treatment, assuming no other injuries are
present except the ones outlined?
A. A client with a blunt chest trauma with some difficulty breathing
B. A client with a sore neck who was immobilized in the field on a backboard with a cervical
collar
C. A client with a possible fractured tibia with adequate pedal pulses
D. A client with an acute onset of confusion
ANS: A
Rationale: The client with blunt chest trauma possibly has a compromised airway. Establishment and
maintenance of a patent airway and adequate ventilation are prioritized over other health problems,
including skeletal injuries and changes in cognition.
PTS: 1 REF: p. 2185
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 67: Emergency Nursing KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
2. A client has sustained multiple injuries from a gunshot wound while hunting in cold winter weather.
The client has waited several hours for rescue and is transported in a helicopter to the emergency
department. The nurse recognizes what additional factors are associated with increased mortality for
this client?
A. Time of injury, hyperhidrosis, and thermal changes
B. Comorbidities, location of injury, and gravitational forces
C. Hypothermia, acidosis, and coagulopathy
D. Venous insufficiency, barometric changes, and fatigue
ANS: C
Rationale: Major trauma can cause hypothermia, acidosis, and coagulopathy, sometimes called the
“triad of death” because each of these factors is associated with increased mortality. In this case the
client was exposed to cold weather for several hours. The client had a gunshot wound that caused
bleeding. Coagulopathy likely occurs immediately after massive trauma and shock. As the client with
trauma perfusion worsens, lactic acid rapidly accumulates in the tissues, which ultimately results in
severe metabolic acidosis. Thermal changes, gravitational forces, barometric changes, and fatigue are
all related to stresses of flight, but they are not directly related to an increased mortality.Comorbidities,
time, and location of injury can contribute to the client’s survivability but are paired with choices that
do not. Venous insufficiency and hyperhidrosis (excessive sweating) are not directly linked to this
event.
PTS: 1 REF: p. 2192
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 67: Emergency Nursing KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
3. The nurse is admitting a client who is suspected of having heat stroke. What assessment finding would
be most consistent with this diagnosis?
A. Widening pulse pressure
B. Hot, dry skin
, C. Core body temperature of 99.0°F/37.2°C
D. Cheyne-Stokes respirations
ANS: B
Rationale: Heat stroke is manifested by hot, dry skin, confusion, bizarre behavior, coma, elevated body
temperature (usually 103°F/39.4°C or higher), tachypnea, hypotension, and tachycardia. A widening
pulse pressure is more indicative of a heart defect or problem. Cheyne-Stokes respirations, a rare
condition characterized by fast, shallow breathing followed by slow heavier breathing, followed by no
breathing, are typically seen in clients with heart failure and stroke.
PTS: 1 REF: p. 2197
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 67: Emergency Nursing KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
4. A client is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours
earlier. The client is alert and oriented. What is the care team's most appropriate treatment?
A. Administering syrup of ipecac
B. Performing a gastric lavage
C. Giving milk to drink
D. Referring to psychiatry
ANS: C
Rationale: A client who has swallowed an acidic substance, such as toilet bowl cleaner, may be given
milk or water to drink for dilution. Gastric lavage must be performed within 1 hour of ingestion. A
psychiatric consult may be considered once the client is physically stable and it is deemed appropriate
by the health care provider. Syrup of ipecac is no longer used in clinical settings.
PTS: 1 REF: p. 2203
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 67: Emergency Nursing KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
5. The paramedics bring a client who has suffered a sexual assault to the ED. What is important for the
sexual assault nurse examiner to do when assessing a sexual assault victim?
A. Respect the client's privacy during assessment.
B. Shave all pubic hair for laboratory analysis.
C. Place items for evidence in plastic bags.
D. Bathe the client before the examination.
ANS: A
Rationale: The client's privacy and sensitivity must be respected because the client will be
experiencing a stress response to the assault. Pubic hair is combed or trimmed for sampling. Paper
bags are used for evidence collection because plastic bags retain moisture, which promotes mold and
mildew that can destroy evidence. Bathing the client before the examination would destroy or remove
key evidence.
PTS: 1 REF: p. 2212 NAT: Client Needs: Psychosocial Integrity
TOP: Chapter 67: Emergency Nursing KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
6. A client with a history of major depression is brought to the ED by the client’s parents. Which of the
following nursing actions is most appropriate?
A. Noting that symptoms of physical illness are not relevant to the current diagnosis
B. Asking if the client has ever thought about taking their own life
, C. Conducting interviews in a brief and direct manner
D. Arranging for the client to spend time alone to consider their feelings
ANS: B
Rationale: Establishing if the client has suicidal thoughts or intents helps identify the level of
depression and intervention. Physical symptoms are relevant and should be explored. Allow the client
to express feelings, and conduct the interview at a comfortable pace for the client. Never leave the
client alone because suicide is usually committed in solitude.
PTS: 1 REF: p. 2215
NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control
TOP: Chapter 67: Emergency Nursing KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
7. The nurse is caring for a client with alcohol withdrawal syndrome. What would be an appropriate
nursing action to minimize the potential for hallucinations?
A. Engage the client in a process of health education.
B. Administer opioid analgesics as prescribed.
C. Place the client in a private, well-lit room.
D. Provide television or a radio as therapeutic distraction
ANS: C
Rationale: The client should be placed in a quiet single room with lights on and in a calm, nonstressful
environment. TV and radio stimulation should be avoided. Analgesics are not normally necessary, and
would potentially contribute to hallucinations. Health education would be inappropriate while the
client is experiencing acute withdrawal.
PTS: 1 REF: p. 2210
NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control
TOP: Chapter 67: Emergency Nursing KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
8. An obtunded client is admitted to the ED after ingesting bleach. The nurse should prepare to assist
with what intervention?
A. Prompt administration of an antidote
B. Gastric lavage
C. Administration of activated charcoal
D. Helping the client drink large amounts of water
ANS: D
Rationale: The client who has ingested a corrosive poison, such as bleach, is given water or milk to
drink for dilution. Gastric lavage is not used to treat ingestion of corrosives and activated charcoal is
ineffective. There is no antidote for a corrosive substance such as bleach.
PTS: 1 REF: p. 2203
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 67: Emergency Nursing KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
9. A client with multiple injuries is brought to the emergency department by ambulance. The client has
had his airway stabilized and is breathing on their own. The nurse does not see any active bleeding, but
should suspect internal hemorrhage based on what finding?
A. Absence of bruising at contusion sites
B. Rapid pulse and decreased capillary refill
C. Increased BP with narrowed pulse pressure
