Chapter 67 Medical Surgical Nursing Preparation For Practice 2nd Edition By Osborn

Chapter 67 Medical Surgical Nursing Preparation For Practice 2nd Edition By Osborn

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCSA

A patient sustained multiple fractures and contusions when hit by a car while walking across the street. He says, “How can I be hurt so badly? The car barely hit me.” How should the nurse respond?

1. “Your body absorbed a lot of energy from the moving car.”
2. “Because you are diabetic, your injuries are worse.”
3. “You probably don’t remember how hard you were hit.”
4. “Because you are older, your injuries are worse.”

Correct Answer: 1

Rationale 1: The nurse can respond with a simple statement that explains the transfer of energy to the patient’s body and the resulting injuries.

Rationale 2: The presence of diabetes does not explain the injuries in this situation.

Rationale 3: There is no indication that the patient sustained injury that would impair memory of the impact.

Rationale 4: The patient’s age does not explain the mechanism of injury.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 67-1

Question 2

Type: MCSA

A patient is admitted to the hospital with injuries from a motor vehicle collision. During the nurse’s initial assessment, the patient develops hypotension and severe jugular distention with a tracheal deviation. The nurse should act quickly to treat which probable condition?

1. Tension pneumothorax
2. Hemorrhage
3. Compensatory shock
4. Hypovolemic shock

Correct Answer: 1

Rationale 1: A tension pneumothorax is life-threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung.

Rationale 2: The patient would not have jugular vein distention with hemorrhage.

Rationale 3: The patient would not have jugular vein distention or tracheal deviation in the presence of compensatory shock.

Rationale 4: Hypovolemic shock is not characterized by jugular vein distention and tracheal deviation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-2

Question 3

Type: MCSA

A patient is admitted with a diagnosis of blunt trauma to the abdomen after a motor vehicle collision. What should the nurse assess first when the patient arrives in the emergency department?

1. Airway patency
2. Abdomen for external signs of injury
3. Cervical spine for tenderness
4. Capillary refill

Correct Answer: 1

Rationale 1: Assessment of the airway, including patency, is the highest priority in the trauma patient.

Rationale 2: This is not the priority assessment.

Rationale 3: The nurse should assess the cervical spine area after the initial ABC assessment.

Rationale 4: Capillary refill is an assessment of circulation but is not the highest priority.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 67-2

Question 4

Type: MCSA

A patient is brought to the emergency department with a penetrating wound to the neck. The patient is dyspneic and cyanotic, and has evidence of subcutaneous emphysema. Which intervention does the nurse prioritize?

1. Intubation
2. Notification of next of kin
3. X-ray of the cervical spine
4. Administration of an IV beta blocker

Correct Answer: 1

Rationale 1: Penetrating trauma to the neck is associated with a high degree of morbidity and mortality. Airway involvement includes dyspnea, cyanosis, subcutaneous emphysema, hoarseness, and air bubbling from the wound. The key is early identification of the need for intubation before the patient has no airway at all.

Rationale 2: The patient is critically injured and next of kin should be notified, but this is not the priority intervention.

Rationale 3: An X-ray evaluation of the cervical spine is important but does not hold the highest priority.

Rationale 4: Medication administration is not the highest priority for this patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 67-2