What is involved when trauma nurses triage a patient in the Emergency Department?
Establishing a meaningful bond with the patient
Starting an IV and putting patient on a heart monitor
Evaluating a patient's health status and doing a physical assessment to look for abnormalities
Taking into account a patients history, age and complaint to determine how urgently they need to be seen by a doctor
The Correct Answer is D
Rationale:
A. While building rapport is important for overall patient care, it is not part of the primary function of triage in the emergency department. Triage focuses on rapidly assessing urgency rather than forming long-term relationships.
B. These interventions may occur after triage for patients who require immediate care, but they are not core components of the triage process itself. Triage is about prioritization, not initiating treatment.
C. Although triage includes a brief assessment, a full physical examination for abnormalities is generally done after triage. Triage is a rapid evaluation, not a detailed diagnostic assessment.
D. Triage involves rapidly assessing the patient’s condition using available information, such as history, presenting complaints, age, vital signs, and observable signs of distress, to determine urgency. This allows the ED to prioritize patients who need immediate intervention while safely delaying care for less urgent cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Spinal shock refers to a temporary loss of all reflexes, sensation, and motor function below the level of a spinal cord injury. It affects neurologic function but does not inherently cause hypotension or bradycardia. While the patient has quadriplegia and may be in spinal shock, this does not explain the vital sign abnormalities observed.
B. Hemorrhagic shock occurs due to blood loss, leading to hypotension and tachycardia as a compensatory response. In this patient, the pulse is bradycardic (52 bpm) rather than tachycardic, which is inconsistent with hemorrhagic shock physiology. Although he has a gunshot wound, his vital signs are not typical of hypovolemic shock.
C. Neurogenic shock occurs after a spinal cord injury, especially above T6, resulting in loss of sympathetic tone. This leads to hypotension (BP 90/50) due to vasodilation and bradycardia (pulse 52) due to unopposed parasympathetic activity. The patient’s C3-C4 quadriplegia and vital signs are classic for neurogenic shock.
D. While the patient may also experience spinal shock neurologically, the hemodynamic findings (bradycardia and hypotension) are specific to neurogenic shock. Hemorrhagic shock is unlikely based on the bradycardia, so “all of the above” is incorrect.
Correct Answer is C
Explanation
Rationale:
A. Hyperflexion injuries occur when the head and neck are forcefully bent forward, often seen in head-on collisions where the occupant’s body moves forward violently. Ms. Joni’s mechanism involved being rear-ended, not a forward bend of the neck.
B. Excessive rotational injuries occur when the head is twisted forcefully relative to the torso, which can injure ligaments or vertebrae. There is no indication that Ms. Joni’s neck was rotated in this manner during the accident.
C. Hyperextension occurs when the head is forcefully thrown backward, stretching and potentially injuring the anterior structures of the cervical spine. Rear-end collisions commonly produce a whiplash mechanism, causing hyperextension of the neck. Ms. Joni’s complaints of neck pain worsened with movement, headache, dizziness, upper back pain, and numbness/tingling in the hands are consistent with cervical hyperextension injury affecting the spinal cord and nerve roots.
D. Axial loading occurs when a force is applied along the vertical axis of the spine, such as from diving into shallow water or a fall landing on the head, which can compress vertebrae. This mechanism does not match the circumstances of Ms. Joni’s rear-end collision.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.