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Worksheetstest Ngoại 81.160
Total questions: 80
Worksheet time: 40mins
The nurse performing neurologic checks every 4 hours for the patient who sustained a head injury. Which early sign indicate a decline in neurologic status?
Nonreactive, dilated pupil
Change in level of consciousness
Decorticate posturing
Loss of remote memory
A nurse is caring for a client who was recently admitted to the emergency department following ahead-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time?
Keep neck stabilized.
Insert NG tube.
Monitor pulse and blood pressure frequently.
Establish IV access and start fluid replacement.
A nurse is caring for a client who has just been admitted from surgery for the evacuation of a subdural hematoma. Which of the following is the priority assessment?
Glasgow Coma Scale
Cranial nerve function
Oxygen saturation level
Pupillary response
A client who has increased ICP has been prescribed mannitol (Osmitrol) IV. For which of the following side effects should the nurse monitor?
Hyperglycemia
Hyponatremia
Hypervolemia
Oliguria
The lesions in the chest cage that it can be seen in chest trauma:
Pneumothorax - haemothorax, lung contusion, chest flail
Lung contusion, flail chest, liver lesion
Haemothorax - pneumothorax, lung contusion, femur fracture
Chest flail, blood clots in the brain, intestinal rupture
List 6 life-threatening chest injuries in chest trauma:
Airway obstruction, pneumothorax tension, cardiac tamponade, open pneumothorax (sucking chest wound), flail chest, massive haemothorax.
Airway obstruction, pneumothorax tension, cardiac tamponade, open pneumothorax (sucking chest wound), flail chest, massive haemothorax
Cardiac tamponade, open pneumothorax (sucking chest wound), clavicle fracture, airway obstructive, flail chest, rib fracture
Physical therapy of respiratory system should be taken
Sitting up early, stimulates coughing, clapping shaking, breathing exercise (blowing balls)
Fowler posture, breathing exercise, stimulates coughing
Not eat and drink, stomach tube, blowing balls
Clapping shaking, stomach tube, completely immobile, infusion
The most important issue when caring for patients after drainage of the pleural cavity:
To ensure good nutrition for the patient, lying motionless
Body hygiene, mental stability to patients
The physical therapy as soon as possible and ensure good drainage system
Antibiotics for patients, enhancing health, anti-pain
Flail chest is :
Rib fracture
Fracture of two ribs and more
Fracture of three ribs and more
Fracture of three consecutive ribs and more, each fractured rib has two fracture positions
The steps in the planning and implementation of care plans chest injuries, chest wounds and flail chest:
Receiving patients, management of shock, prepare to drain pleural
Prevent and management of shock, management of respiratory failure, control infection, make preparation for patient, prepare drainage of pleural
Management of respiratory failure, control pain, prepare drainage of pleural, management of shock
Management of shock, control infection, make preparation for patient, prepare drainage of pleural
Monitor circulation need follow
Monitor pulse, blood pressure, number of drainage, skin color, mucous, blood formula test; monitor bleeding at the other location & call doctor.
Monitor breathing; chest tube, color skin, mucosa; ultrasound; monitor bleeding at the other location & call doctor.
Monitor respiratory; chest tube, computerized tomography of chest, blood biochemical tests; monitor bleeding at the other location & call doctor.
Monitor pulse, chest tube; respiration, blood tests, check the open chest wound.
Counters skills of breathing per minute
See the up and down mobile of chest per minute
Listen to the lung sound per minute
See the up and down mobile of abdominal wall per minute
To hand on the abdominal wall and count the number of mobile of the abdominal wall per minute
Chest trauma: operative indication in all cases
True
False
Principles for chest tube: closed, continuous suction and one-way, sterile
True
False
Respiratory physical therapy plays an important role in postoperative care to chest tube
True
False
All flail chest cases are treated with mechanical ventilation method
True
False
Rib fractures with chest tube, especially the elderly: respiratory physical therapy and nursing care is not required
True
False
Pain symptom is always show in chest wounds
True
False
Tension pneumothorax (valve pneumothorax) management of emergencies like the other type of pneumothorax
True
False
Need replacement pleural drainage bottle daily for nursing care chest tube
True
False
Clotted blood and retained haemothorax never show in the chest wound
True
False
All chest wounds should always indicate operation to manage injuries
True
False
Respiratory physical therapy need: patients always lie in bed and not be taken analgesics
True
False
A nurse is caring for a client who has a compound fracture of the right forearm that was recently casted. Which of the following is an early sign of neurovascular compromise?
Paresthesia.
Pulselessness
Paralysis
Polar.
A nurse is stabilizing for a client who has a compound fracture of the right arm. Which did he/she have to do before?
Elevate the limb and apply ice.
Place the client in supine position.
Cover open wounds with a sterile dressing.
Remove clothing and jewelry near injury.
Casts secure the arm fracture in order to:
Prevent further injury, reduce pain, and promote circulation.
Prevent further injury, reduce pain, and correct a deformity.
Reduce pain, promote circulation, and correct a deformity.
Prevent further injury, reduce pain, promote healing and correct a deformity.
Use the short-arm cast for:
Distal radial fracture.
Fracture of ulna.
Fracture of radia.
Fracture of the thumb.
Use the long-arm cast for:
Fracture of humeral shaft.
Fracture of distal humerus.
Fracture of proximal humerus.
Fracture of humeral head.
The 3 disadvantages of external fixation for the arm, except:
Pin site infection.
Potential overwhelming appearance.
Early mobilization.
Noncompliance.
A nurse is caring for client who had open reduction and internal fixation for the radius 7 days ago. Which of following is a sign of infection:
Swelling at the site of incision.
Erythema and edema at the site of incision.
Loss of function.
Loss of sensation.
A nurse is caring for a client who has fracture of the right forearm that was recently casted. The client complains of more pain after cast. What action should the nurse do?
Remove cast and reassessment.
Change another cast and reassessment.
Loosening cast and reassessment.
Remove cast and use another immobilizer.
An indication of traction for the arm fracture exclude:
Type of traction.
Traction time.
Traction weight.
Pin site care.
Traction is more effective than cast in:
Decreasing pain.
Decreasing muscle spasm.
Preventing neurovascular injury.
Promoting circulation.
The most valuable sign to diagnose radius fracture is:
Swelling.
Crepitus.
Pain.
Tenderness.
The most valuable sign to diagnose humerus fracture is:
Loss of forearm function.
Deformity of the arm.
Arm bruising
Swelling.
The most effective procedure to diagnose arm fracture is:
Two view x-rays.
Bone scan.
MRI.
Ultrasound.
A nurse is caring for a client who has fracture of the right arm that was recently applied standard side-arm skeletal traction. The client complains of more pain after traction. What action should the nurse do?
Maintain body alignment and realign.
Remove weights.
Stop traction.
Give some analgesics to the client.
A nurse is caring for a client who has fracture of the right arm that was recently applied standard side-arm skeletal traction. The client complains of severe pain after traction. What action should the nurse do?
Reduce some weights of traction.
Remove traction, apply cast.
Notify this problem to provider.
Give some analgesics and muscle relaxants to the client.
What makes for displaced fractures?
Large muscle groups spasm
Disrupted muscles
Fractures fragments
Broken bone size
How many stages occur during bone healing?
4
5
6
3
What time period the stage 3 takes place?
1-3 days
3 days to 2 weeks
2-6 weeks
6 weeks to 1 years
“Callus formation” occurs in:
stage 1
stage 2
stage 3
stage 4
“Fibrocartilage formation” occurs in:
stage 1
stage 2
stage 3
stage 4
Which of the following is the UNFAVORABLE factors for bone healing process?
Minimal damage to soft tissue
Anatomic reduction possible
Effective immobilization
Fragments widely separated
Which of the following is the FAVORABLE factors for bone healing process?
Fragments distracted by traction
Severe comminuted fracture
Bone loss from injury or surgical excision
Anatomic reduction possible
The following factors AFFECT the bone healing process, except:
Weight bearing on long bones
Location
Sex
Decreased blood supply
Which of the following is the most significant signs of fracture?
Bruising
Muscle spasm
Abnormal mobility and crepitus
Pain
Which of the following is the GOALS of medical management:
Discover all injuries
Reduction and stabilization of the fracture
Monitoring for complications
a+b+c
Which of the following is INCORRECT?
Assessment and treatment are performed simultaneously
During primary assessment, the rescuer forcuses on airway management, bleeding, and manifestations of the shock
Any potentially life-threatening injuries must be stabilized immediately
An injured client should be moved althought the current location is not safe
Which of the following is the GOALS of reduction?
To restore alignment, position, and length
To make sure that the bone have been broken
To permit the client can walk
To rescue the client from shock
Which of the following is INCORRECT for closed reduction?
To perform closed reduction, a health care provider applies manual traction to move the fracture fragments and restore bone alignment
Closed reduction should be performed as soon as possible
Fracture reduction is an emergency procedure
An immobilization device must be applied after x-ray
Which of the following is INCORRECT for closed reduction?
The immobilizer most commonly used after closed reduction is a traction
The immobilizer most commonly used after closed reduction is a cast
The immobilizer most commonly used after closed reduction is a polymer of plaster
Cast are used for prevention or correction of deformity; maintenance; support; and protection of realigned bone
Which of the following is CORRECT for Open Reduction and Internal Fixation?
The surgeon makes an incision and realigns the fracture fragments under direct visualization
Realignment of the fracture fragments without any incision
Open reduction is usually performed in combination with internal fixation by plates, screws, nails, wires
Internal fixation provides essential immobilization and helps to prevent deformity, but it is not a substitute for bone healing
Which of the following is NOT complication after fracture?
Blood Vessel injury
Nerve injury
Brain-sick
Compartment Syndrome
Which of the following NEEDN’T in care of the client in a Cast?
Neurovascular Assessment
Assessment of Pain
Assessment of the Cast
Assessment of the Knee Movement
Which statement best describes the preoperative period?
It begins when the patient makes the appointment with the surgeon to discuss the need for surgery.
It is the time during which the patient receives education and testing related to the impending surgery.
It is a time during which the patient’s need for surgery and willingness to have it is established
It begins when the patient is scheduled for surgery and ends at the time of transfer to the surgical suite.
The patient is scheduled for resection of nerve roots. What type of surgery is this?
Palliative
Restorative
Diagnostic
Ablative
Specify whether the urgency of the surgery is elective (EL), urgent (U), or emergent (EM): A 22-year-old nursing student is scheduled for an appendectomy.
EL
U
EM
Specify whether the urgency of the surgery is elective (EL), urgent (U), or emergent (EM): A 77 year-old woman is scheduled for a total knee replacement.
EL
U
EM
Specify whether the urgency of the surgery is elective (EL), urgent (U), or emergent (EM): A 55 year-old man is scheduled for a colon resection due to a small bowel obstruction.
EL
U
EM
The nurse screens the preoperative patient for conditions that may increase the risk for complications during the perioperative period. Which condition is a possible risk factor
The patient is 70 years old and obese.
The procedure planned is a bunionectomy
The patient is 5 feet tall and weighs 100 pounds.
The surgery is planned as an ambulatory/same-day surgical procedure
The nurse functions as the patient advocate by reporting to the surgeon and anesthesiology personnel any abnormalities found on the physical assessment.
T
F
Throughout the physical assessment, the nurse focuses on the problem areas identified from the patient’s history that are limited to body systems affected directly by the surgical procedure.
T
F
In the preoperative setting, the nurse is functioning as a patient advocate when the patient’s home environment, self-care capabilities, and support systems are assessed and used in the discharge planning process.
T
F
As a patient advocate, the nurse can provide the patient with educational materials appropriate to the patient’s ability to learn.
T
F
When the nurse evaluates preoperative laboratory test values, only abnormal values related to the surgery need to be reported to the surgeon and anesthesiology personnel.
T
F
Patients who have had minor outpatient surgery do not usually require discharge planning.
T
F
Which statement is true regarding the patient who has given consent for a surgical procedure?
Information necessary to understand the nature of and reason for the surgery has been provided.
The length of stay in the hospital has been preapproved by the managed care provider.
Information about the surgeon’s experience has been provided.
The nurse has provided detailed information about the surgical procedure.
Which statement best describes the collaborative roles of the nurse and surgeon when obtaining the informed consent?
The nurse is responsible for having the in-formed consent form on the chart for the physician to witness.
The nurse may serve as a witness that the patient has been informed by the physician before surgery is performed.
The nurse may serve as witness to the patient’s signature after the physician has the consent form signed before preoperative sedation is given and before surgery is performed.
The nurse has no duties regarding the consent form if the patient has signed the informed consent form for the physician, even if the patient then asks additional questions about the surgery.
The nurse has received the patient in the holding area who is scheduled for a left breast biopsy. What is the priority safety measure for this patient before surgery?
Ensure the patient knows who will be performing the surgery.
Ask the patient to mark the site with a marker.
Instruct the patient to perform leg exercises to prevent a deep vein thrombosis.
Determine who the support persons are for the patient.
The diabetic patient is scheduled for surgery in the morning. Which procedure does the nurse expect on the morning of surgery?
Usual dose of insulin will be given to maintain the patient’s blood glucose level.
Increased dose of insulin will be given to offset the physical stress caused by the procedure.
Modified dose of insulin will be given, based on the patient’s blood glucose.
No insulin will be given because the patient is NPO.
What percentage of all hospital trauma admissions involve renal trauma?
Approximately 3%
Approximately 10%
Approximately 13%
Approximately 20%
What is the key clinical symptom of the kidney trauma?
Flank pain
Hematuria (gross or microscopic)
Abdominal distention
Fever
What is the following finding on clinical examination indicating possible renal involvement?
Fever
Flank ecchymoses or abdominal mass
Flank pain
Abdominal distention
True or False: The presence or absence of hematuria is not a good indicator of traumatic injury
T
F
True or False: Hematuria is a hallmark sign of renal trauma, but is neither sensitive nor specific enough for differentiating minor and major injuries
T
F
A small cortical laceration in the kidney with a small perirenal hematoma would be classified as what grade injury?
Grade I
Grade II
Grade III
Grade IV
A renal parenchymal laceration extending through the contex into the renal medulla would be classified as what grade injury?
Grade I
Grade II
Grade III
Grade IV
What are the indications for imaging of the kidneys following blunt trauma?
Gross hematuria or microhematuria combined with shock
Rib fracture
Microhematuria without signs of shock
Abdominal distention
Staging of renal trauma is best accomplished with what radiographic test?
Ultrasonography
Standard intravenous pyelography
CT scanner
Magnetic resonance imaging
