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Complex Adult Health Exam 1Study Questions And Actual Answers.

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  • Course
  • Collaborative Adult Health
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  • Collaborative Adult Health

1. An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this clients care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse - Answer ANS: C All other...

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  • November 19, 2024
  • 70
  • 2024/2025
  • Exam (elaborations)
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  • Collaborative Adult Health
  • Collaborative Adult Health
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Complex Adult Health Exam 1Study
Questions And Actual Answers.
1. An emergency room nurse assesses a client who has been raped. With which health care team
member

should the nurse collaborate when planning this clients care?

a. Emergency medicine physician

b. Case manager

c. Forensic nurse examiner

d. Psychiatric crisis nurse - Answer ANS: C

All other members of the health care team listed may be used in the management of this clients care.
However,

the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the
assault,

and can offer the counseling and follow-up needed when dealing with the victim of an assault.

DIF: Understanding/Comprehension REF: 118

KEY: Interdisciplinary team| emergency nursing

MSC: Integrated Process: Nursing Process: Planning

NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care



2. The emergency department team is performing cardiopulmonary resuscitation on a client when the
clients

spouse arrives at the emergency department. Which action should the nurse take first?

a. Request that the clients spouse sit in the waiting room.

b. Ask the spouse if he wishes to be present during the resuscitation.

c. Suggest that the spouse begin to pray for the client.

d. Refer the clients spouse to the hospitals crisis team. - Answer ANS: B

If resuscitation efforts are still under way when the family arrives, one or two family members may be
given

the opportunity to be present during lifesaving procedures. The other options do not give the spouse the

,opportunity to be present for the client or to begin to have closure.

DIF: Applying/Application REF: 126

KEY: Death| emergency nursing MSC: Integrated Process: Caring

NOT: Client Needs Category: Psychosocial Integrity



3. An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive
care

first?

a. A 30-year-old distraught mother holding her crying child

b. A 65-year-old conscious male with a head laceration

c. A 26-year-old male who has pale, cool, clammy skin

d. A 48-year-old with a simple fracture of the lower leg - Answer ANS: C

The client with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother
does

not have injuries and so would be the lowest priority. The other two people need medical attention
soon, but

not at the expense of a person in shock.

DIF: Applying/Application REF: 129

KEY: Triage| emergency nursing

MSC: Integrated Process: Nursing Process: Implementation

NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care



4. While triaging clients in a crowded emergency department, a nurse assesses a client who presents
with

symptoms of tuberculosis. Which action should the nurse take first?

a. Apply oxygen via nasal cannula.

b. Administer intravenous 0.9% saline solution.

c. Transfer the client to a negative-pressure room.

d. Obtain a sputum culture and sensitivity. - Answer ANS: C

,A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a
negativepressure room to prevent contamination of staff, clients, and family members in the crowded
emergency

department.

DIF: Applying/Application REF: 120

KEY: Infection control| Transmission-Based Precautions| emergency nursing| staff safety

MSC: Integrated Process: Nursing Process: Implementation

NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control



5. A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize
to

receive care first?

a. A 22-year-old with a painful and swollen right wrist

b. A 45-year-old reporting chest pain and diaphoresis

c. A 60-year-old reporting difficulty swallowing and nausea

d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F - Answer ANS: B

A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged

immediately to a treatment room in the ED. The other clients are more stable.

DIF: Applying/Application REF: 123

KEY: Triage| emergency nursing

MSC: Integrated Process: Nursing Process: Planning

NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care



6. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired
with the

level of the trauma center?

a. Level I Located within remote areas and provides advanced life support within resource capabilities

b. Level II Located within community hospitals and provides care to most injured clients

c. Level III Located in rural communities and provides only basic care to clients

, d. Level IV Located in large teaching hospitals and provides a full continuum of trauma care for all clients
- Answer ANS: B

Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum
of

trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals.

These trauma centers provide care for most clients and transport to Level I centers when client needs
exceed

resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These
centers

provide basic care, stabilization, and advanced life support while transfer arrangements to higher-level
trauma

centers are made.

DIF: Remembering/Knowledge REF: 127

KEY: Trauma center| emergency nursing

MSC: Integrated Process: Nursing Process: Planning

NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care



7. Emergency medical technicians arrive at the emergency department with an unresponsive client who
has an

oxygen mask in place. Which action should the nurse take first?

a. Assess that the client is breathing adequately.

b. Insert a large-bore intravenous line.

c. Place the client on a cardiac monitor.

d. Assess for the best neurologic response. - Answer ANS: A

The highest-priority intervention in the primary survey is to establish that the client is breathing
adequately.

Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing

inadequately with the device in place.

Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 51

DIF: Applying/Application REF: 128

KEY: Primary survey| emergency nursing

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