Chapter 34 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 34 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCSA

Which consideration will the nurse apply to the assessment of a patient who sustained penetrating trauma?

1. The extent of injury is related to the amount of energy transferred to the body tissues.
2. The amount of trauma sustained is related to the patient’s nutritional status before the injury.
3. If the patient was well hydrated at the time of injury, the extent will be diminished.
4. The primary determinant of injury is the arc traveled by the penetrating object.

Correct Answer: 1

Rationale 1: Penetrating trauma refers to injury sustained by the transmission of energy to body tissues from a moving object that interrupts skin integrity. Penetrating trauma produces actual tissue penetration and may also cause surrounding tissue deformation based on the energy transferred by the penetrating object.

Rationale 2: Pre-injury nutritional status is not a major factor in the amount of injury sustained.

Rationale 3: The patient’s fluid volume status has little to do with the amount of injury sustained.

Rationale 4: The physics of injury does include arc, direction of travel, diameter of the object, and other components, but these measures all relate to a more specific concept.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-3

 

Question 2

Type: MCSA

A 14-year-old white male is brought into the emergency room of an urban hospital with a penetrating wound caused by the accidental discharge of a gun. Which risk factor for this injury pattern would the nurse rank as the most influential?

1. Living in an urban area
2. Being white
3. Age
4. Gender

Correct Answer: 4

Rationale 1: Risk for unintentional injury is higher in rural areas. Rate for intentional injury is higher in urban areas.

Rationale 2: Native Americans have the highest death rates from unintentional injury.

Rationale 3: The risk of injury is highest for those 15 through 24.

Rationale 4: The risk for males is 2.5 times that of females, possibly because of male involvement in hazardous activities.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-1

 

Question 3

Type: MCSA

A patient was injured when the car he was driving hit a telephone pole. The patient is 6 feet tall and weighs 200 pounds. The car was traveling at approximately 25 miles per hour when it hit the 36 inch diameter wooden pole. The nurse would calculate which pounds per square inch of impact for this patient?

1. 833.3
2. 30,000
3. 5000
4. 12,245

Correct Answer: 3

Rationale 1: This is an incorrect measurement of this impact.

Rationale 2: This is an incorrect measurement of this impact.

Rationale 3: To calculate pounds per square inch of impact, the nurse would multiply the patient’s weight by the speed the car was traveling. For this situation, the calculation would be 200 lb × 25 miles per hour, which means the patient sustained 5000 lb per square inch of impact.

Rationale 4: This is an incorrect measurement of this impact.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-2

 

Question 4

Type: MCSA

A patient brought into the emergency department with injuries sustained from a motor vehicle accident (MVA) is complaining of abdominal pain and begins to vomit. The nurse suspects injury from which most likely source?

1. Shearing
2. Deceleration
3. Compression
4. Acceleration

Correct Answer: 3

Rationale 1: Shearing occurs when two parts of the same structure move in opposite direction causing a tear. Shearing forces are common in MVAs, but this is not the most specific injury pattern for this patient.

Rationale 2: Deceleration is a decrease in the speed of velocity of a moving object. Deceleration injury is common in MVAs but is not the most specific injury in this situation.

Rationale 3: Compression is the process of being pressed or squeezed together with a resulting reduction in volume or size. The small bowel may be compressed between the vertebral column and the lower part of the steering wheel or an improperly placed seat belt. The bowel may rupture. Because the patient complained of abdominal pain and started to vomit, the nurse should suspect that the patient sustained a compression force injury.

Rationale 4: Acceleration is the increase in the rate of velocity or speed of a moving object and frequently occurs in MVAs. It is not the most specific injury pattern suggested by this scenario.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-2