NUR HEAD-LEG TRAUMA & SHOCK UPDATED EXAM QUESTIONS AND ANSWERS 100% A+ GRADED
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Course
TRAUMA (TRAUMA)
Institution
Chamberlain College Of Nursing
CASE STUDY 13 Head and Leg Trauma and Shock
Ms. A is a 20-year-old college student who had been drinking at a fraternity party before she fell from a second-floor balcony. Paramedics were called by one of the more sober students at the party, and Ms. A has just arrived in the emergency department...
NUR HEAD-LEG TRAUMA & SHOCK
UPDATED EXAM QUESTIONS AND
ANSWERS 100% A+ GRADED
CASE STUDY 13 Head and Leg Trauma and Shock
Ms. A is a 20-year-old college student who had been drinking at a
fraternity party before she fell from a second-floor balcony. Paramedics
were called by one of the more sober students at the party, and Ms. A has
just arrived in the emergency department (ED). A fellow college student
who accompanies Ms. A tells you, “She was completely knocked out right
after the fall. But then she woke up a little, so we thought she was okay—
until she stopped moving again.”
You are assigned as the ED triage nurse. When you assess Ms. A, there is
no response to commands or to having her name called. She extends her
arms and legs stiffly when nail bed pressure is applied, but there is still no
verbal response. Her eyes are shut, and she does not open them even
with the nail bed pressure. When you open her eyelids, you see that her
pupils are unequal, with the right pupil larger than the left. The pupil
response when you shine a flashlight into her eyes is sluggish.
Ms. A's blood pressure is 70/30 mm Hg, she is in a sinus bradycardia with
a rate of 40 beats/min, and her respiratory rate is 6 breaths/min. Her
respirations are irregular, and she has 20-second periods of apnea. You
note that she has a large occipital laceration and that her left leg is
misaligned.
The paramedics have a cervical collar and backboard in place. A 16-
gauge catheter has been inserted at the left antecubital area and lactated
Ringer solution is infusing at 150 mL/hr.
1. Which additional assessment information is most important to
obtain at this time?
1. Temperature
2. Breath sounds
3. Pedal pulses
4. Oxygen saturation
,NUR HEAD-LEG TRAUMA & SHOCK
UPDATED EXAM QUESTIONS AND
ANSWERS 100% A+ GRADED
2. Which is the best way to clearly document Ms. A's level of
consciousness (LOC)?
1. Client has a decreased LOC.
2. Client is unresponsive.
3. Client GCS score = 4.
4. Client is comatose.
3. When describing Ms. A's neurologic assessment, you will chart
“Client demonstrates __________________ posturing in response to nail
bed pressure.”
4. Based on Ms. A's vital signs, she appears to be in shock. Which
types of shock are you most concerned about for this client? (Select all
that apply.)
1. Cardiogenic
2. Hypovolemic
3. Neurogenic
4. Septic
5. Anaphylactic
5. You are working with Dr. G, a new medical resident whose first
day in the ED rotation is today. Which action by Dr. G indicates that you
need to consult quickly with the supervising physician?
1. Dr. G assesses for the Babinski sign.
2. Dr. G increases the intravenous (IV) infusion rate to 200 mL/hr.
3. Dr. G orders an electrocardiogram taken at once (stat).
4. Dr. G prepares to perform a lumbar puncture.
6. After you perform triage for Ms. A, which ED staff member will
you assign to take primary responsibility for Ms. A's ongoing care?
, NUR HEAD-LEG TRAUMA & SHOCK
UPDATED EXAM QUESTIONS AND
ANSWERS 100% A+ GRADED
1. An RN from a temporary agency with extensive previous ED
experience who has been in your ED for 3 days
2. An LPN with 10 years of experience in your ED who is in the last
semester of an RN program
3. An RN who has worked in your ED for the last 5 years after
transferring from the mother-baby unit
4. An RN who has 12 years of experience in the intensive care unit
(ICU) and has floated to the ED today
7. Ms. A suddenly begins to vomit. Which action should the nurse
take first?
1. Utilize the backboard to log-roll Ms. A to her side
2. Suction Ms. A's airway with a Yankauer suction device
3. Hyperoxygenate Ms. A with a bag valve mask system
4. Insert a nasogastric tube and connect to low suction
The results of laboratory tests that were performed when Ms. A arrived in
the ED are faxed to the RN. Complete blood count results are as follows:
Hematocrit
42%
Hemoglobin level
12.6 g/dL
Platelet count
200,000/mm3
White blood cell count
7500/mm3
The metabolic profile shows the following:
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