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Exam (elaborations)

Test Bank for Mental Health Nursing Exam 1 – Varcarolis NCLEX-Style Questions and Answers

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Extensive set of NCLEX-style questions and answers covering Exam 1 topics from Varcarolis' Psychiatric Mental Health Nursing, including recovery-focused care, therapeutic communication, psychiatric diagnoses, and major theories.

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Medical Surgical Nursing
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Medical surgical nursing
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Medical surgical nursing

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Uploaded on
May 1, 2025
Number of pages
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Written in
2024/2025
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Chapter 10: Concepts of Emergency and
Trauma Nursing Ignatavicius:
Medical-Surgical Nursing, 10th Edition


1. 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?
a. Primary health care provider
b. Case manager
c. Forensic nurse examiner
d. Psychiatric crisis nurse - ANS ANS: C
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.

2. The emergency department team is performing cardiopulmonary resuscitation on a
client when the client's spouse arrives. Which action would the nurse take first?
a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he or she
wishes to be present during the resuscitation.
c. Suggest that the spouse begin to pray for the patient. d. Refer the client's spouse to
the hospital's crisis team. - ANS ANS: B
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.

3. An emergency department nurse is triaging victims of a multi-casualty event. Which
client would receive care first?
a. A 30-year-old distraught mother holding her crying child
b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48 year old with a simple fracture of the lower leg - ANS ANS: C
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.

4. 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?
a. Apply oxygen via nasal cannula.
b. Administer intravenous 0.9% saline solution.
c. Transfer the client to a negative-pressure room.
d. Obtain a sputum culture and sensitivity. - ANS ANS: C
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.

5. A nurse is triaging clients in the emergency department (ED). Which client would the
nurse prioritize to receive care first?
a. A 22 year old with a painful and swollen right wrist
b. A 45 year old reporting chest pain and diaphoresis
c. A 60 year old reporting difficulty swallowing and nausea
d. An 81 year old, respiratory rate 28 breaths/min and temperature of 101° F (38.8° C) -
ANS ANS: B
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

6. A nurse is evaluating levels and functions of trauma centers. Which function is
appropriately paired with the level of the trauma center?
a. Level I—located within remote areas and provides advanced life support within
resource capabilities
b. Level II—located within community hospitals and provides care to most injured clients
c. Level III—located in rural communities and provides only basic care to clients
d. Level IV—located in large teaching hospitals and provides a full continuum of trauma
care for all clients - ANS ANS: B
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

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