ANSWERS WITH ACCURATE
RATIONALES(PASSED).
- correct answer -
1. The nurse is caring for a patient who was thrown from a horse and has a
decreased level of consciousness, decorticate posturing and hyperthermia.
These findings are consistent with
A. diffuse axonal injury
B. subdural hematoma.
C. Epidural hematoma.
D. Intracerebral hematoma. - correct answer - A. diffuse axonal injury
2. A patient who has a chest tube continues to have decreased breath
sounds on the affected side and asymmetrical chest wall movement with
each breath. The nurse notes a large amount of bubbling in the water seal
chamber and subcutaneous air from the neck to the abdomen. The nurse
should suspect A. pneumothorax progressing to a tension pneumothorax.
B. multiple rib fractures and a flail chest.
C. hollow organ injury.
D. tracheobronchial tree injury. - correct answer -
3. A patient who is 36 weeks pregnant was a restrained driver in a high-
speed motor vehicle crash on the driver's side. Assessment reveals
abdominal pain, uterine tenderness on palpation, and rising fundal height.
Vital signs are: BP 84/40 mmHg HR 136 beats/min The nurse should be
concerned about
A. vena cava syndrome.
B. placenta previa.