Chapter 10: Concepts of Emergency and Trauma Nursing

An emergency department nurse assesses a client who has been raped. With which health care team member would the nurse

collaborate when planning this client’s care?

• Primary health care provider

• Case manager

• Forensic nurse examiner

• Psychiatric crisis nurse

Answer explanation

All other members of the health care team listed may be used in the management of this client’s 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.

The emergency department team is performing cardiopulmonary resuscitation on a client when the client’s spouse arrives. Which

action would the nurse take first?

• Request that the client’s spouse sit in the waiting room.

• Ask the spouse if he or she wishes to be present during the resuscitation.

• Suggest that the spouse begin to pray for the patient.

• Refer the client’s spouse to the hospital’s crisis team.

Answer explanation

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.

An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first?

• A 30-year-old distraught mother holding her crying child

• A 65-year-old conscious male with a head laceration

• A 26-year-old male who has pale, cool, clammy skin

• A 48 year old with a simple fracture of the lower leg

Answer explanation

The client with pale, cool, clammy skin may be 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.

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis.

Which action would the nurse take first?

• Apply oxygen via nasal cannula.

• Administer intravenous 0.9% saline solution.

• Transfer the client to a negative-pressure room.

• Obtain a sputum culture and sensitivity.

Answer explanation

A client with signs and symptoms of tuberculosis or other airborne pathogens would be placed in a negative-pressure room to

prevent contamination of staff, clients, and family members in the crowded emergency department. The client may or may not need

oxygen or an IV. A sputum culture would be obtained but is not the priority.

A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first?

• A 22 year old with a painful and swollen right wrist

• A 45 year old reporting chest pain and diaphoresis

• A 60 year old reporting difficulty swallowing and nausea

• An 81 year old, respiratory rate 28 breaths/min and temperature of 101° F

Answer explanation

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.

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma

center?

• Level I—located within remote areas and provides advanced life support within

  resource capabilities

• Level II—located within community hospitals and provides care to most injured

  clients

• Level III—located in rural communities and provides only basic care to clients

• Level IV—located in large teaching hospitals and provides a full continuum of

  trauma care for all clients

Answer explanation

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.

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place.

Which action would the nurse take first?

• Assess that the client is breathing adequately.

• Insert a large-bore intravenous line.

• Place the client on a cardiac monitor.

• Assess for the best neurologic response.

Answer explanation

After establishing an airway, 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. Inserting an IV line and placing the client on a monitor would come after ensuring a patent airway and effective

breathing.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action would the nurse

take prior to providing advanced cardiac life support?

• Contact the on-call orthopedic surgeon.

• Don personal protective equipment.

• Notify the Rapid Response Team.

• Obtain a complete history from the paramedic.

Answer explanation

Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation.

Standard Precautions would 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. It is

not known if this client has orthopedic injuries. The Rapid Response Team is not needed in the ED. A complete history is needed

but the staff’s protection comes first.

A nurse is triaging clients in the emergency department. Which client would be considered “urgent”?

• A 20-year-old female with a chest stab wound and tachycardia

• A 45-year-old homeless man with a skin rash and sore throat

• A 75-year-old female with a cough and a temperature of 102° F (38.9° C)

• A 50-year-old male with new-onset confusion and slurred speech

Answer explanation

A client with a cough and a temperature of 102° F (38.9° C) 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 would 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.

An emergency department nurse is caring for a client who has died from a suspected homicide. Which action does the nurse take?

• Remove all tubes and wires in preparation for the medical examiner.

• Limit the number of visitors to minimize the family’s trauma.

• Consult the bereavement committee to follow up with the grieving family.

• Communicate the client’s death to the family in a simple and concrete manner.

Answer explanation

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 would be allowed to view the body. Offering to call for additional family support

during the crisis is suggested. The bereavement committee would be consulted, but this is not the priority at this time.