Medical-Surgical Nursing: Concepts for Interprofessional
Collaborative Care (11th Ed.),
Unit II: Emergency Care & Disaster Preparedness.
Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
1
Reference: Ch. 10: Concepts of Emergency and Trauma Nursing
— Primary survey (A of ABCDE)
Question stem: A 58-year-old man arrives to the ED after a
motor-vehicle collision. He is conscious but lethargic and has
obvious facial trauma. During the primary survey, which action
should the nurse perform first?
A. Obtain a full set of vital signs.
B. Assess airway patency and protect the cervical spine.
C. Establish two large-bore IV lines.
D. Complete a focused neurologic exam.
,Correct answer: B
Rationale — Correct: In trauma, airway with cervical spine
protection (A of primary survey) is the immediate priority to
prevent hypoxia and secondary spinal injury. Rapid airway
assessment with manual inline stabilization is indicated.
Rationale — A: Vital signs are important but come after airway
assessment in primary survey.
Rationale — C: IV access is essential but secondary to assuring
airway and breathing.
Rationale — D: Detailed neuro exam is part of secondary survey
after ABCs are stabilized.
Teaching point: In trauma, secure airway while protecting the
cervical spine before other interventions.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 10:
Concepts of Emergency and Trauma Nursing.
2
Reference: Ch. 10: Concepts of Emergency and Trauma Nursing
— Triage and prioritization
Question stem: The triage nurse in a busy ED receives four
patients at once. Which patient should be triaged as highest
priority for immediate evaluation?
A. A 34-year-old with localized ankle pain after twisting it while
running.
,B. A 72-year-old with sudden left-sided weakness and slurred
speech for 20 minutes.
C. A 25-year-old with a superficial laceration to the forearm that
is bleeding and controllable.
D. A 50-year-old with suspected acute gastroenteritis and
vomiting.
Correct answer: B
Rationale — Correct: Signs of acute stroke (sudden unilateral
weakness and speech changes) require immediate evaluation
and time-sensitive interventions (e.g., thrombolysis window).
Rationale — A: Isolated ankle injury is lower acuity.
Rationale — C: Controllable superficial bleeding is not
immediately life- or limb-threatening.
Rationale — D: Gastroenteritis symptoms are generally lower
priority unless unstable.
Teaching point: Time-sensitive neurologic deficits require
immediate triage and rapid stroke protocol activation.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 10:
Concepts of Emergency and Trauma Nursing.
3
Reference: Ch. 10: Concepts of Emergency and Trauma Nursing
— Shock types and nursing priorities
, Question stem: A patient in the ED is hypotensive (BP 78/40),
tachycardic, warm extremities, and bounding pulses after a
severe burn injury with large fluid losses. Which type of shock is
most consistent with these findings and requires which
immediate nursing action?
A. Cardiogenic shock — give IV morphine to reduce myocardial
oxygen demand.
B. Hypovolemic shock — begin rapid crystalloid fluid
resuscitation.
C. Distributive (septic) shock — start broad-spectrum antibiotics
immediately.
D. Obstructive shock — prepare for emergent
pericardiocentesis.
Correct answer: B
Rationale — Correct: Large burns commonly cause hypovolemic
(or distributive early) physiology from fluid loss; hypotension
and tachycardia with a history of fluid loss prompt rapid
crystalloid resuscitation as first-line.
Rationale — A: Cardiogenic shock presents with signs of pump
failure (cool, weak pulses); morphine is not first-line emergency.
Rationale — C: While distributive/septic shock shows warm
extremities, the scenario of burns with fluid losses points to
hypovolemia and need for volume replacement; antibiotics are
not immediate first action for hypovolemia.
Rationale — D: Obstructive shock has specific causes
Collaborative Care (11th Ed.),
Unit II: Emergency Care & Disaster Preparedness.
Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
1
Reference: Ch. 10: Concepts of Emergency and Trauma Nursing
— Primary survey (A of ABCDE)
Question stem: A 58-year-old man arrives to the ED after a
motor-vehicle collision. He is conscious but lethargic and has
obvious facial trauma. During the primary survey, which action
should the nurse perform first?
A. Obtain a full set of vital signs.
B. Assess airway patency and protect the cervical spine.
C. Establish two large-bore IV lines.
D. Complete a focused neurologic exam.
,Correct answer: B
Rationale — Correct: In trauma, airway with cervical spine
protection (A of primary survey) is the immediate priority to
prevent hypoxia and secondary spinal injury. Rapid airway
assessment with manual inline stabilization is indicated.
Rationale — A: Vital signs are important but come after airway
assessment in primary survey.
Rationale — C: IV access is essential but secondary to assuring
airway and breathing.
Rationale — D: Detailed neuro exam is part of secondary survey
after ABCs are stabilized.
Teaching point: In trauma, secure airway while protecting the
cervical spine before other interventions.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 10:
Concepts of Emergency and Trauma Nursing.
2
Reference: Ch. 10: Concepts of Emergency and Trauma Nursing
— Triage and prioritization
Question stem: The triage nurse in a busy ED receives four
patients at once. Which patient should be triaged as highest
priority for immediate evaluation?
A. A 34-year-old with localized ankle pain after twisting it while
running.
,B. A 72-year-old with sudden left-sided weakness and slurred
speech for 20 minutes.
C. A 25-year-old with a superficial laceration to the forearm that
is bleeding and controllable.
D. A 50-year-old with suspected acute gastroenteritis and
vomiting.
Correct answer: B
Rationale — Correct: Signs of acute stroke (sudden unilateral
weakness and speech changes) require immediate evaluation
and time-sensitive interventions (e.g., thrombolysis window).
Rationale — A: Isolated ankle injury is lower acuity.
Rationale — C: Controllable superficial bleeding is not
immediately life- or limb-threatening.
Rationale — D: Gastroenteritis symptoms are generally lower
priority unless unstable.
Teaching point: Time-sensitive neurologic deficits require
immediate triage and rapid stroke protocol activation.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 10:
Concepts of Emergency and Trauma Nursing.
3
Reference: Ch. 10: Concepts of Emergency and Trauma Nursing
— Shock types and nursing priorities
, Question stem: A patient in the ED is hypotensive (BP 78/40),
tachycardic, warm extremities, and bounding pulses after a
severe burn injury with large fluid losses. Which type of shock is
most consistent with these findings and requires which
immediate nursing action?
A. Cardiogenic shock — give IV morphine to reduce myocardial
oxygen demand.
B. Hypovolemic shock — begin rapid crystalloid fluid
resuscitation.
C. Distributive (septic) shock — start broad-spectrum antibiotics
immediately.
D. Obstructive shock — prepare for emergent
pericardiocentesis.
Correct answer: B
Rationale — Correct: Large burns commonly cause hypovolemic
(or distributive early) physiology from fluid loss; hypotension
and tachycardia with a history of fluid loss prompt rapid
crystalloid resuscitation as first-line.
Rationale — A: Cardiogenic shock presents with signs of pump
failure (cool, weak pulses); morphine is not first-line emergency.
Rationale — C: While distributive/septic shock shows warm
extremities, the scenario of burns with fluid losses points to
hypovolemia and need for volume replacement; antibiotics are
not immediate first action for hypovolemia.
Rationale — D: Obstructive shock has specific causes
