Chapter 08: Concepts of Emergency and Trauma Nursing
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
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.
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.
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.
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
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.
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.
,ANS: C
A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in
a negative- pressure room to prevent contamination of staff, clients, and family members in the
crowded emergency department.
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
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.
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
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.
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.
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.
8. A trauma client with multiple open wounds is brought to the emergency department in cardiac
arrest. Which action should the nurse take prior to providing advanced cardiac life support?
a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
, d. Obtain a complete history from the paramedic.
ANS: B
Nurses must recognize and plan for a high risk of contamination with blood and body fluids when
engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation
situations and at other times when exposure to blood and body fluids is likely. Proper attire
consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and
shoe covers.
9. A nurse is triaging clients in the emergency department. Which client should be considered
urgent?
a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
c. A 75-year-old female with a cough and a temperature of 102 F
d. A 50-year-old male with new-onset confusion and slurred speech
ANS: C
A client with a cough and a temperature of 102 F is urgent. This client is at risk for deterioration
and needs to be seen quickly, but is not in an immediately life-threatening situation. The client
with a chest stab wound and tachycardia and the client with new-onset confusion and slurred
speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk
for deterioration and would be triaged as nonurgent.
10. An emergency department nurse is caring for a client who has died from a suspected
homicide. Which action should the nurse take?
a. Remove all tubes and wires in preparation for the medical examiner.
b. Limit the number of visitors to minimize the family’s trauma.
c. Consult the bereavement committee to follow up with the grieving family.
d. Communicate the clients death to the family in a simple and concrete manner.
ANS: D
When dealing with clients and families in crisis, communicate in a simple and concrete manner to
minimize confusion. Tubes must remain in place for the medical examiner. Family should be
allowed to view the body. Offering to call for additional family support during the crisis is
suggested. The bereavement committee should be consulted, but this is not the priority at this
time.
11. An emergency department (ED) case manager is consulted for a client who is homeless.
Which intervention should the case manager provide?
a. Communicate client needs and restrictions to support staff.
b. Prescribe low-cost antibiotics to treat community-acquired infection.
c. Provide referrals to subsidized community-based health clinics.
d. Offer counseling for substance abuse and mental health disorders.
ANS: C
Case management interventions include facilitating referrals to primary care providers who are
accepting new clients or to subsidized community-based health clinics for clients or families in
need of routine services. The ED nurse is accountable for communicating pertinent staff
considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation
, precautions) to ensure that ongoing client and staff safety issues are addressed. The ED
physician prescribes medications and treatments. The psychiatric nurse team evaluates clients
with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including
possible admission to an appropriate psychiatric facility.
12. An emergency department nurse is caring for a client who is homeless. Which action should
the nurse take to gain the clients trust?
a. Speak in a quiet and monotone voice.
b. Avoid eye contact with the client.
c. Listen to the clients concerns and needs.
d. Ask security to store the clients belongings.
ANS: C
To demonstrate behaviors that promote trust with homeless clients, the emergency room nurse
should make eye contact (if culturally appropriate), speak calmly, avoid any prejudicial or
stereotypical remarks, show genuine care and concern by listening, and follow through on
promises. The nurse should also respect the clients belongings and personal space.
13. A nurse is triaging clients in the emergency department. Which client should the nurse
classify as nonurgent?
a. A 44-year-old with chest pain and diaphoresis
b. A 50-year-old with chest trauma and absent breath sounds
c. A 62-year-old with a simple fracture of the left arm
d. A 79-year-old with a temperature of 104 F
ANS: C
A client in a nonurgent category can tolerate waiting several hours for health care services
without a significant risk of clinical deterioration. The client with a simple arm fracture and
palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and
would be considered nonurgent. The client with chest pain and diaphoresis and the client with
chest trauma are emergent owing to the potential for clinical deterioration and would be seen
immediately. The client with a high fever may be stable now but also has a risk of deterioration.
MULTIPLE RESPONSE
1.A nurse is caring for clients in a busy emergency department. Which actions should the nurse
take to ensure client and staff safety? (Select all that apply.)
a. Leave the stretcher in the lowest position with rails down so that the client can access the
bathroom.
b. Use two identifiers before each intervention and before mediation administration.
c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.
d. Search the belongings of clients with altered mental status to gain essential medical
information.
e. Isolate clients who have immune suppression disorders to prevent hospital-acquired
infections.
ANS: B, C, D
To ensure client and staff safety, nurses should use two identifiers per The Joint Commissions
National Patient Safety Goals; follow the hospitals security plan, including de-escalation
strategies for people who demonstrate aggressive or violent tendencies; and search belongings
to identify essential medical information. Nurses should also use standard fall prevention
