Chapter 26: Emergency or Life-Threatening Situations
Ball: Seidel’s Guide to Physical Examination, 9th Edition
MULTIPLE CHOICE
1. During initial ABCDE assessments of life-threatening conditions, D (disability) in neurologic
status is assessed by the patient’s:
a. pupil size.
b. degree of responsiveness.
c. nuchal rigidity.
d. mood and affect.
ANS: B
The D (disability) in neurologic status of the primary assessment is assessed by determination of
the patient’s degree of responsiveness to stimuli.
DIF: Cognitive Level: Remembering (Knowledge)
OBJ: Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort
2. You have gone by ambulance to a construction site where an adult male is lying on the street.
The only information you have is that he fell three stories. His neck is immobilized with sacks of
concrete mix on either side. Your first action should be to determine:
a. airway patency.
b. bleeding sites.
c. cranial nerve function.
d. limb position.
ANS: A
On arriving at the site, the patency of the upper airway is the priority and should be managed
before proceeding with further assessments.
DIF: Cognitive Level: Applying (Application)
OBJ: Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort
3. The ABCs of a primary survey would be interrupted to:
a. complete the assessment record.
b. manage life-threatening conditions.
c. reassess the patient’s temperature.
d. transport the patient via airlift.
ANS: B
The primary assessment is interrupted to manage a life-threatening condition as soon as it is
detected. Once the condition is stabilized, the primary assessment is continued. Recording of
events as they occur should be completed in a manner that does not interrupt continued care or
transport. Reassessment of the patient’s temperature is inappropriate because it would interrupt
the continued assessment process. Transporting the patient may begin after the primary
assessment has been completed to determine the needs of the patient adequately.
DIF: Cognitive Level: Applying (Application)
OBJ: Nursing process—implementing MSC: Safe and Effective Care: Management of Care
, 4. The term status epilepticus is defined as:
a. convulsive activity uncontrolled by medication.
b. nonconvulsive brain wave disturbance, with psychomotor dysfunction.
c. prolonged seizures that occur without recovery of consciousness.
d. seizures that result in hypotension, pallor, and prolonged diaphoresis.
ANS: C
Status epilepticus is a prolonged seizure or series of seizures that occur without recovery of
consciousness.
DIF: Cognitive Level: Remembering (Knowledge)
OBJ: Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort
5. Pulsus paradoxus greater than 20 mm Hg, tachycardia greater than 130 beats/min, and
increasing dyspnea are signs of:
a. intracranial pressure.
b. pulmonary hypertension.
c. status asthmaticus.
d. tetanic contractions.
ANS: C
Status asthmaticus is a severe and prolonged asthma attack that resists the usual therapeutic
approaches. The patient experiences dyspnea, can only get out a few words between breaths, and
has tachycardia often greater than 130 beats/min and pulsus paradoxus greater than 20 mm Hg.
Pulsus paradoxus is more likely in pericardial effusion, constrictive pericarditis, and severe
asthma.
DIF: Cognitive Level: Analyzing (Analysis) OBJ: Nursing process—diagnosis
MSC: Physiologic Integrity: Basic Care and Comfort
6. The Cushing triad includes:
a. tachycardia.
b. irregular respirations.
c. tachypnea.
d. constricted pupils.
ANS: B
The Cushing triad is associated with increased intracranial pressure. It includes bradycardia,
hypertension, and irregular respirations, even Cheyne-Stokes respirations.
DIF: Cognitive Level: Remembering (Knowledge) OBJ: Nursing process—diagnosis
MSC: Physiologic Integrity: Basic Care and Comfort
7. Blood, vomitus, and foreign bodies are removed from the oropharynx of the unconscious
patient by:
a. stimulating the cough reflex.
b. using a sweeping motion with the finger.
c. performing a back thrust.
d. using suction.
ANS: D
Suction is used to remove blood, vomitus, or foreign bodies from the airway of an unconscious
patient. The other choices put the patient at risk for aspiration or further injury if a neck injury is
involved.
DIF: Cognitive Level: Applying (Application)
Ball: Seidel’s Guide to Physical Examination, 9th Edition
MULTIPLE CHOICE
1. During initial ABCDE assessments of life-threatening conditions, D (disability) in neurologic
status is assessed by the patient’s:
a. pupil size.
b. degree of responsiveness.
c. nuchal rigidity.
d. mood and affect.
ANS: B
The D (disability) in neurologic status of the primary assessment is assessed by determination of
the patient’s degree of responsiveness to stimuli.
DIF: Cognitive Level: Remembering (Knowledge)
OBJ: Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort
2. You have gone by ambulance to a construction site where an adult male is lying on the street.
The only information you have is that he fell three stories. His neck is immobilized with sacks of
concrete mix on either side. Your first action should be to determine:
a. airway patency.
b. bleeding sites.
c. cranial nerve function.
d. limb position.
ANS: A
On arriving at the site, the patency of the upper airway is the priority and should be managed
before proceeding with further assessments.
DIF: Cognitive Level: Applying (Application)
OBJ: Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort
3. The ABCs of a primary survey would be interrupted to:
a. complete the assessment record.
b. manage life-threatening conditions.
c. reassess the patient’s temperature.
d. transport the patient via airlift.
ANS: B
The primary assessment is interrupted to manage a life-threatening condition as soon as it is
detected. Once the condition is stabilized, the primary assessment is continued. Recording of
events as they occur should be completed in a manner that does not interrupt continued care or
transport. Reassessment of the patient’s temperature is inappropriate because it would interrupt
the continued assessment process. Transporting the patient may begin after the primary
assessment has been completed to determine the needs of the patient adequately.
DIF: Cognitive Level: Applying (Application)
OBJ: Nursing process—implementing MSC: Safe and Effective Care: Management of Care
, 4. The term status epilepticus is defined as:
a. convulsive activity uncontrolled by medication.
b. nonconvulsive brain wave disturbance, with psychomotor dysfunction.
c. prolonged seizures that occur without recovery of consciousness.
d. seizures that result in hypotension, pallor, and prolonged diaphoresis.
ANS: C
Status epilepticus is a prolonged seizure or series of seizures that occur without recovery of
consciousness.
DIF: Cognitive Level: Remembering (Knowledge)
OBJ: Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort
5. Pulsus paradoxus greater than 20 mm Hg, tachycardia greater than 130 beats/min, and
increasing dyspnea are signs of:
a. intracranial pressure.
b. pulmonary hypertension.
c. status asthmaticus.
d. tetanic contractions.
ANS: C
Status asthmaticus is a severe and prolonged asthma attack that resists the usual therapeutic
approaches. The patient experiences dyspnea, can only get out a few words between breaths, and
has tachycardia often greater than 130 beats/min and pulsus paradoxus greater than 20 mm Hg.
Pulsus paradoxus is more likely in pericardial effusion, constrictive pericarditis, and severe
asthma.
DIF: Cognitive Level: Analyzing (Analysis) OBJ: Nursing process—diagnosis
MSC: Physiologic Integrity: Basic Care and Comfort
6. The Cushing triad includes:
a. tachycardia.
b. irregular respirations.
c. tachypnea.
d. constricted pupils.
ANS: B
The Cushing triad is associated with increased intracranial pressure. It includes bradycardia,
hypertension, and irregular respirations, even Cheyne-Stokes respirations.
DIF: Cognitive Level: Remembering (Knowledge) OBJ: Nursing process—diagnosis
MSC: Physiologic Integrity: Basic Care and Comfort
7. Blood, vomitus, and foreign bodies are removed from the oropharynx of the unconscious
patient by:
a. stimulating the cough reflex.
b. using a sweeping motion with the finger.
c. performing a back thrust.
d. using suction.
ANS: D
Suction is used to remove blood, vomitus, or foreign bodies from the airway of an unconscious
patient. The other choices put the patient at risk for aspiration or further injury if a neck injury is
involved.
DIF: Cognitive Level: Applying (Application)
