T HREATENING S ITUATIONS
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 asses sment 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