Chapter 24 Questions

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response.

ANS: A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place.

A patient was thrown 30 feet from an open-top Jeep and straddled a row of mailboxes before she landed on the ground. She has an open pelvic fracture. The nurse admitting the patient into the ICU knows that a. aggressive fluid and blood replacement will probably be needed. b. the patient will probably be able to walk as soon as she is hemodynamically stable. c. she will probably not need surgery to stabilize her fracture. d. there is little likelihood of damage to the genitourinary or gastrointestinal tracts.

ANS: A The mortality rate for these injuries is high because unlike closed pelvic fractures that bleed into the peritoneum, open pelvic fractures result in external exsanguinations.

A patient in the neurologic intensive care unit has an endotracheal tube. When the nurse does the hourly Glasgow Coma Scale assessment, what rating would this patient have for verbal response? 1. 1 2. 4 3. 2 4. 3

1. 1 Correct Answer: 1 *Rationale 1: The Glasgow Coma Scale assesses both level of consciousness and motor response to a stimulus. The scale has three sections: eye opening, motor response, and verbal response. If the patient is unable to talk because of intubation, the score is a 1. * Rationale 2: The patient is unable to talk and would not be scored as a 4. Rationale 3: The patient is unable to talk and would not be scored as a 2. Rationale 4: The patient is unable to talk and would not be scored as a 3.

Immediate interventions for a patient with a sucking chest wound include: Select all that apply. 1. Administer pain medication. 2. Continue to monitor pulse oximetry and respiratory characteristics. 3. Prepare for emergency intubation. 4. Prepare the patient for chest tube insertion. 5. Apply a dressing that is taped on three sides.

1. Administer pain medication. 2. Continue to monitor pulse oximetry and respiratory characteristics. 4. Prepare the patient for chest tube insertion. 5. Apply a dressing that is taped on three sides. Correct Answer: 1,2,4,5 *Rationale 1: Pain medication will allow an ease in the breathing effort and reduce pain on insertion of the chest tube. Rationale 2: The nurse will continuously monitor pulse oximetry and respiratory characteristics. * Rationale 3: Emergency intubation may not be required because the patient can still breathe. The problem is not the effort to inhale or exhale air but to expand the collapsed lung tissue and prevent pressure buildup in the enclosed lung cavity. *Rationale 4: Chest tubes are used to reinflate lung tissue by creating a negative pressure. Rationale 5: A sucking chest wound sucks atmospheric air into the chest cavity with each breath. Closing off this air will decrease the collapse of lung tissue by using a dressing that allows air to leave the chest cavity (thus not taping all four sides) but decreasing the intake of air on inhalation.*

Which nursing assessment would have highest priority for early airway management of a trauma patient? 1. Ask the patient to state his name. 2. Assess increasing intracranial pressure (ICP) with facial fractures. 3. Prepare for emergency tracheostomy. 4. Perform a computerized tomography (CT) scan of tissues of the neck.

1. Ask the patient to state his name. Correct Answer: 1 *Rationale 1: If the patient can state his name audibly then the airway is patent.* Rationale 2: ICP monitoring might be needed but it is not the first priority of the nurse for airway issues. Rationale 3: Emergency tracheostomy might be needed but it is still a second action only if needed. Rationale 4: CT scanning might be needed but it is not the first priority of the nurse for airway issues.

A nurse notes that a patient with a traumatic brain injury is having a rapid decline in level of consciousness. If the nurse suspects cerebral herniation the most appropriate intervention would be to: 1. Briefly hyperventilate the patient. 2. Take measures to increase intracranial pressures by Trendelenburg positioning. 3. Prepare for emergency surgical repair. 4. Contact the family to come say their last words with the patient.

1. Briefly hyperventilate the patient. Correct Answer: 1 *Rationale 1: Hyperventilating the patient lowers the ICP by lowering the PaCO2 that is causing vasoconstriction of the cerebral blood vessels and reducing cerebral blood flow. * Rationale 2: This position places the patient at greater risk of permanent damage from decreased cerebral blood flow. Rationale 3: Emergency surgery might be needed but hyperventilating the patient will temporarily allow more time for informed decision making. Rationale 4: Although this may be a life and death event, the activity that might reduce this risk can be temporarily avoided by hyperventilation first.

When managing shock, which statement would be incorrect when comparing the level or classification of shock to the drug treatment? 1. Class I-treated with blood products 2. Class II-treated with isotonic fluids 3. Class III-treated with isotonic fluids and blood products 4. Class IV-treated with blood and fluids

1. Class I-treated with blood products Correct Answer: 1 *Rationale 1: Class I-treated with colloid fluid resuscitation is incorrect and should be treated with isotonic fluids. * Rationale 2: This is the correct treatment for Class II shock. Rationale 3: This is the correct treatment for Class III shock. Rationale 4: This is the correct treatment for Class IV shock.

While caring for a patient with thoracic injuries from a motor vehicle crash, the nurse suspects the patient is developing cardiac tamponade because of which assessment findings? Select all that apply. 1. Dropping blood pressure 2. Jugular vein distention 3. Muffled heart sounds 4. Drop in blood pressure on inspiration 5. Increase in blood pressure on inspiration

1. Dropping blood pressure 2. Jugular vein distention 3. Muffled heart sounds 4. Drop in blood pressure on inspiration Correct Answer: 1,2,3,4 *Rationale 1: Hypotension is an assessment finding within Beck's triad indicating cardiac tamponade. Rationale 2: An increase in central venous pressure assessed as jugular vein distention is an assessment finding within Beck's triad indicating cardiac tamponade. Rationale 3: Heart sounds are muffled in cardiac tamponade because of the accumulation of fluid in the pericardial sac. This is an assessment finding within Beck's triad indicating cardiac tamponade. Rationale 4: In paradoxical pulse, blood pressure is at least 10 mm Hg higher on expiration than on inspiration. This is an assessment finding of cardiac tamponade. * Rationale 5: In cardiac tamponade, the blood pressure is higher on expiration than inspiration.

What can the nurse do to convey comfort to a trauma patient? Select all that apply. 1. Explain and talk to the patient, not ignore the patient. 2. Give clear precise directions to follow. 3. Directly look at the eyes of the patient when talking. 4. Human contact such as a reassuring touch. 5. Giving all details to get full cooperation.

1. Explain and talk to the patient, not ignore the patient. 2. Give clear precise directions to follow. 3. Directly look at the eyes of the patient when talking. 4. Human contact such as a reassuring touch. Correct Answer: 1,2,3,4 *Rationale 1: This will convey comfort to a trauma patient. Rationale 2: This will convey comfort to a trauma patient. Rationale 3: This will convey comfort to a trauma patient. Rationale 4: This will convey comfort to a trauma patient. * Rationale 5: Giving extensive details will delay care and often confuses the patient in a traumatic situation and increases the patient's anxiety rather than reducing stress. A patient under stress can best comprehend and follow brief directions given in a comforting manner to allow the staff to do their job without having to over explain or rationalize why they are doing what they are doing during the "golden" hour that may mean the difference between life and death.

A patient with traumatic injuries to the abdomen expresses the fear of dying. What can the nurse do to provide comfort to the patient at this time? Select all that apply. 1. Face the patient when talking. 2. State phrases that demonstrate care and comfort. 3. Hold the patient's hand. 4. Provide pain medication. 5. Leave the patient to rest.

1. Face the patient when talking. 2. State phrases that demonstrate care and comfort. 3. Hold the patient's hand. Correct Answer: 1,2,3 *Rationale 1: Using the en face position is comforting to a patient with traumatic injuries. Rationale 2: Using comfort talk is helpful to the patient with traumatic injuries. Rationale 3: Providing physical contact by holding the patient's hand provides comfort to the patient with traumatic injuries. * Rationale 4: The use of pain medication is not identified as an intervention to provide comfort to the patient with traumatic injuries. Rationale 5: Leaving the patient alone is not identified as an intervention of comfort to the patient with traumatic injuries.

The nurse identifies that a patient is at risk for the development of reoccurring cardiac tamponade when: 1. Fluid or blood continues to accumulate in the pericardial sac. 2. The cause of the tamponade was persistent hypertension. 3. Treatment by needle aspiration of the fluid in the sac is performed. 4. A pericardial window is surgically created.

1. Fluid or blood continues to accumulate in the pericardial sac. Correct Answer: 1 *Rationale 1: Unless immediate treatment is initiated, the tamponade will reoccur. * Rationale 2: Cardiac tamponade is not caused by hypertension. Rationale 3: This is a treatment to repair cardiac tamponade. Rationale 4: This is a treatment to repair cardiac tamponade.

The nurse is preparing to complete the secondary survey of a patient admitted with a traumatic chest injury. On what will the nurse focus when conducting this survey? Select all that apply. 1. Full set of vital signs 2. Comfort measures 3. Head-to-toe assessment 4. Assessment of posterior surfaces 5. Exposure

1. Full set of vital signs 2. Comfort measures 3. Head-to-toe assessment 4. Assessment of posterior surfaces Correct Answer: 1,2,3,4 *Rationale 1: This is a part of the secondary trauma survey. Rationale 2: This is a part of the secondary trauma survey. Rationale 3: This is a part of the secondary trauma survey. Rationale 4: This is a part of the secondary trauma survey. * Rationale 5: This is a part of the primary trauma survey.

A patient is admitted with injuries sustained from a skiing accident. While completing the primary survey, the nurse suspects the patient has an injury to the spleen because of which findings? Select all that apply. 1. Heart rate 120 2. Referred pain to the left shoulder 3. Upper left quadrant abdominal pain 4. Hematuria 5. Flank ecchymosis

1. Heart rate 120 2. Referred pain to the left shoulder 3. Upper left quadrant abdominal pain Correct Answer: 1,2,3 *Rationale 1: A rapid heart rate can indicate hemorrhage or hypovolemic shock which is an assessment finding consistent with an injury to the spleen. Rationale 2: Kehr's sign is referred pain to the left shoulder. This is an assessment finding consistent with an injury to the spleen. Rationale 3: Upper left quadrant abdominal tenderness or pain is an assessment finding consistent with an injury to the spleen.* Rationale 4: Hematuria is not an assessment finding consistent with an injury to the spleen. Rationale 5: Bruising or ecchymosis over the flank area is not an assessment finding consistent with an injury to the spleen.

The nurse assesses a patient with a penetrating abdominal wound as a Class IV hemorrhage because of which findings? Select all that apply. 1. Heart rate 160 2. Respiratory rate 28 3. Mean arterial pressure 50 4. Capillary refill 5 seconds 5. Mild decrease in urine output

1. Heart rate 160 2. Respiratory rate 28 3. Mean arterial pressure 50 4. Capillary refill 5 seconds Correct Answer: 1,2,3,4 *Rationale 1: Heart rate greater than 140 is an indication of Class IV hemorrhage. Rationale 2: Tachypnea is an indication of Class IV hemorrhage. Rationale 3: Mean arterial pressure less than 60 is an indication of Class IV hemorrhage. Rationale 4: Delayed capillary refill is an indication of Class IV hemorrhage. * Rationale 5: Mild decrease in urine output would be seen in a Class II hemorrhage.

The nurse is concerned that a patient receiving emergency care for maxillofacial injuries from a motor vehicle crash sustained laryngeal trauma because of which assessment findings? Select all that apply. 1. Hoarse speech 2. Pain when swallowing 3. Coughing blood 4. Epistaxis 5. Periorbital edema

1. Hoarse speech 2. Pain when swallowing 3. Coughing blood Correct Answer: 1,2,3 *Rationale 1: The patient with laryngeal trauma will demonstrate hoarse speech. Rationale 2: Painful swallowing is a manifestation of laryngeal trauma. Rationale 3: Hemoptysis is a manifestation of laryngeal trauma.* Rationale 4: Epistaxis is not a manifestation of laryngeal trauma but would be present because of the maxillofacial trauma. Rationale 5: Periorbital edema is not a manifestation of laryngeal trauma but would be present because of the maxillofacial trauma.

The nurse is caring for a patient with a traumatic injury to the abdomen who is prescribed conservative, non-operative management. Which ongoing assessments should the nurse include in the plan of care? Select all that apply. 1. Hourly vital signs 2. Assessment of the degree and type of guarding or rigidity 3. Hourly CVP readings 4. ECG changes for bradycardia and widening QRS 5. Widening pulse pressure

1. Hourly vital signs 2. Assessment of the degree and type of guarding or rigidity 3. Hourly CVP readings Correct Answer: 1,2,3 *Rationale 1: This would be done in the patient with a traumatic abdominal injury to assess for peritonitis. Rationale 2: This would be done in the patient with a traumatic abdominal injury to assess for peritonitis. Rationale 3: This would be done to assess fluid status and the onset of hypovolemic shock in the patient with a traumatic abdominal injury. * Rationale 4: The ECG will show tachycardia from hypovolemia. Widening QRS show slowed conduction in the ventricles and would not be a sign of abdominal distress. Rationale 5: Widening pulse pressure is not seen in the patient with traumatic abdominal injury.

Which will the nurse assess when evaluating breathing in a patient suspected of having a thoracic trauma? Select all that apply. 1. Jugular vein distention 2. Symmetry of chest movement bilaterally 3. Chest movements that rise and fall with breathing effort 4. Respiratory rate, pattern, and effort 5. Peripheral skin coloring

1. Jugular vein distention 2. Symmetry of chest movement bilaterally 3. Chest movements that rise and fall with breathing effort 4. Respiratory rate, pattern, and effort Correct Answer: 1,2,3,4 *Rationale 1: Jugular vein distention will increase when chest pressure rises with displacement or fluid buildup in which the heart must work harder to circulate the blood and perfuse tissues that are hypoxic. Rationale 2: Chest movement symmetry will be assessed in the patient with thoracic trauma. Rationale 3: Chest movements that rise and fall with breathing will be assessed in the patient with thoracic trauma. Rationale 4: Respiratory rate, pattern, and effort will be assessed in the patient with thoracic trauma. * Rationale 5: Skin coloring is a circulation issue, not a breathing issue.

The nurse is planning interventions for a trauma patient to prevent the onset of the lethal triad. What will the nurse include in this patient's plan of care? Select all that apply. 1. Monitor temperature. 2. Measure intake and output. 3. Evaluate laboratory data. 4. Assess arterial blood gas values. 5. Measure gastric pH.

1. Monitor temperature. 2. Measure intake and output. 3. Evaluate laboratory data. 4. Assess arterial blood gas values. Correct Answer: 1,2,3,4 *Rationale 1: Monitoring body temperature is critical in the prevention of deaths from the lethal triad. Rationale 2: Measuring intake and output is critical in the prevention of deaths from the lethal triad. Rationale 3: Evaluating recent laboratory data is critical in the prevention of deaths from the lethal triad. Rationale 4: Assessing arterial blood gas values is critical in the prevention of deaths from the lethal triad. * Rationale 5: Measuring gastric pH is not critical in the prevention of deaths from the lethal triad.

In the patient with thoracic trauma, what would the nurse identify as potential problems? Select all that apply. 1. Pleural effusion 2. Subcutaneous emphysema 3. Tracheal shift 4. Vertebral column injury 5. Bladder rupture

1. Pleural effusion 2. Subcutaneous emphysema 3. Tracheal shift 4. Vertebral column injury Correct Answer: 1,2,3,4 *Rationale 1: Tears in lung tissue and fluid accumulation in the pleural space will decrease the gas exchange at the capillary level and/or at the airflow through the trachea. Rationale 2: Tears in lung tissue will decrease the gas exchange at the capillary level and/or at the airflow through the trachea. Rationale 3: Displacement of underlying structures will decrease the gas exchange at the capillary level and/or at the airflow through the trachea. Rationale 4: Displacement of underlying structures will decrease the gas exchange at the capillary level and/or at the airflow through the trachea. * Rationale 5: Bladder rupture would occur as a potential complication with abdominal trauma and not as likely with a thoracic trauma.

Which goals are appropriate for a patient with a traumatic injury and an ineffective breathing pattern? Select all that apply. 1. Provide oxygen 100% therapy through a nonrebreather mask. 2. Restore the normal breathing pattern. 3. Maintain a calm environment to decrease oxygen demands. 4. Prevent sepsis 5. Maintain balanced hydration

1. Provide oxygen 100% therapy through a nonrebreather mask. 2. Restore the normal breathing pattern. 4. Prevent sepsis Correct Answer: 1,2,4 *Rationale 1: This will maximize available oxygen and allow the least respiratory effort to increase perfusion to the greatest number of alveolar areas. Rationale 2: This will maximize available oxygen and allow the least respiratory effort to increase perfusion to the greatest number of alveolar areas.* Rationale 3: Although remaining calm will decrease the oxygen demand, this is not likely to occur when breathing difficulties create both physical and emotional stress. Sedation may be needed if ventilation is in use and the patient is fighting the ventilator. *Rationale 4: Preventing infection will allow the least respiratory effort to increase perfusion in the greatest number of alveolar areas. * Rationale 5: Although keeping the lung tissue moist is the ideal way to improve cellular tissue exchange, it will not help if the problem is ineffective breathing. The muscle effort or surface available to exchange is the problem that needs correction.

During the assessment of a patient with a suspected cardiac tamponade, the nurse should monitor for the development of: Select all that apply. 1. Pulsus paradoxus 2. Muffled heart sounds 3. Hypotension 4. Flat jugular veins

1. Pulsus paradoxus 2. Muffled heart sounds 3. Hypotension Correct Answer: 1,2,3 *Rationale 1: This is a symptom of cardiac tamponade. Rationale 2: This is a symptom of cardiac tamponade. Rationale 3: This is a symptom of cardiac tamponade. * Rationale 4: Jugular vein distention would increase, not decrease, with the increasing backup of blood and the decreasing contractility from the limited motion of the ventricles as fluid/blood builds up within the sac, limiting its ability to move.

A patient with massive injuries to the head and chest has died. The family is in the hallway waiting to see the patient. What can the nurse do to prepare the family to be with the patient at this time? Select all that apply. 1. Remove blood soaked bed sheets and gown. 2. Have at least one of the patient's hands readily available for the family to touch. 3. Place the stretcher in the low position. 4. Turn one dim light on in the room. 5. Leave the family to visit with the patient.

1. Remove blood soaked bed sheets and gown. 2. Have at least one of the patient's hands readily available for the family to touch. 3. Place the stretcher in the low position. 4. Turn one dim light on in the room. Correct Answer: 1,2,3,4 *Rationale 1: The nurse should remove body fluids from the environment. Rationale 2: The nurse should make sure the patient's hand is out and secured. Rationale 3: The nurse should make sure the stretcher is in the low position so that chairs can be placed around it. Rationale 4: Turning on one dim light in the room calms the room. * Rationale 5: The nurse should be present to answer questions and provide support.

The nurse would include which activities when planning care to increase comfort for the intubated patient? Select all that apply. 1. Speak directly to the patient by looking into the patient's eyes. 2. Keep the patient sedated and let the patient sleep when giving care. 3. Give additional pain medication whenever restlessness is noted. 4. Establish a communication method that does not require talking. 5. Keep the family at the bedside to interpret the patient's needs.

1. Speak directly to the patient by looking into the patient's eyes. 4. Establish a communication method that does not require talking. Correct Answer: 1,4 *Rationale 1: Developing eye contact will give comfort and reassurance when the patient is unable to speak while intubated. * Rationale 2: Sedation and not talking to the patient do not give support to the patient. Sedation may be needed but explaining the reason and timing for such should be for the improved ventilatory effectiveness and not the nurse's convenience. Rationale 3: Pain medication needs to be given based on the patient's interpretation of its need. Restlessness is often a symptom of hypoxia and further assessment needs to be done before just medicating the patient. *Rationale 4: Developing a separate method of communication such as blinking one's eyes or squeezing the nurse's hand will give comfort and reassurance when the patient is unable to speak while intubated. * Rationale 5: It is not the family's role to communicate or to meet the needs of the patient. It is a nursing obligation to identify and meet the needs of the patient.

What will the nurse expect to assess in a patient with a tension pneumothorax? 1. Tracheal deviation to the unaffected side 2. Bilateral equal chest movement 3. Decreased muscular effort by chest muscles 4. Decreasing central venous pressure (CVP)

1. Tracheal deviation to the unaffected side Correct Answer: 1 *Rationale 1: As air accumulates on the pleural space with no place to escape, the affected lung collapses and the resulting increase on intrathoracic pressure puts pressure on the trachea, which causes displacement to the unaffected side. * Rationale 2: Normal breathing is bilaterally equal. In a tension pneumothorax, one or more areas of the lung tissue collapses and does not expand, therefore limiting the chest movement on that side. Therefore, the movement is bilaterally unequal. Rationale 3: Increased muscle effort will be the response to decreasing lung activity. Extra muscles of the chest are called into place to try to increase the effort to move the air within the lung tissues. Rationale 4: The CVP will increase to try to compensate for decreased pulmonary perfusion from a decrease in the surface area for oxygen to be exchanged.

Fat embolism syndrome can occur as a complication of a. liver trauma. b. burns. c. orthopedic trauma. d. spleen trauma.

ANS: C Fat embolism syndrome can occur as a complication of orthopedic trauma.

A patient with a head injury has a pO2 of 88 and a pCO2 of 58. The nurse realizes that which physiologic process will occur in this patient? 1. Cerebral blood vessels will constrict. 2. Cerebral blood vessels will dilate. 3. Blood flow to the cerebral cortex will slow. 4. Blood will be shunted from the cerebral cortex.

2. Cerebral blood vessels will dilate. Correct Answer: 2 Rationale 1: This is not an expected physiologic response to the patient's oxygen and carbon dioxide levels. *Rationale 2: Autoregulation ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such as when there is a drop in cerebral oxygen levels or an increase in cerebral carbon dioxide levels.* Rationale 3: This is not an expected physiologic response to the patient's oxygen and carbon dioxide levels. Rationale 4: This is not an expected physiologic response to the patient's oxygen and carbon dioxide levels.

Which assessment finding indicates that a trauma patient is having problems with breathing rather than difficulty maintaining an airway? 1. Pain with swallowing, coughing, or hemoptysis 2. Chest pain on inspiration 3. Popping sound (crepitus) in the throat when touching the skin by the trachea 4. Hoarseness when talking

2. Chest pain on inspiration Correct Answer: 2 Rationale 1: Each of these symptoms is an example of an airway maintenance issue that can contribute to decreased airflow through the throat. *Rationale 2: Chest pain is a breathing issue and not an airway problem. * Rationale 3: Crepitus is noted with laryngeal fractures where air is escaping into the subcutaneous tissue. Rationale 4: This is an example of an airway maintenance issue that can contribute to decreased airflow through the throat.

Which risk factors could lead to the development of airway failure if not recognized while assessing the airway of a trauma patient? Select all that apply. 1. Chest wall injury 2. Displacement of the trachea (tracheal shift) 3. Aspiration of gastric contents 4. Foreign object occlusion of the throat/mouth 5. Swelling of soft tissue in the throat

2. Displacement of the trachea (tracheal shift) 3. Aspiration of gastric contents 4. Foreign object occlusion of the throat/mouth 5. Swelling of soft tissue in the throat Correct Answer: 2,3,4,5 Rationale 1: The chest wall injury would be a breathing survey assessment because it focuses on thoracic trauma and the ability to ventilate and not obstruct the airway itself. *Rationale 2: This can obstruct the airflow into or out of the lungs and cause airway failure. Rationale 3: This can obstruct the airflow into or out of the lungs and cause airway failure. Rationale 4: This can obstruct the airflow into or out of the lungs and cause airway failure. Rationale 5: This can obstruct the airflow into or out of the lungs and cause airway failure.*

A patient who has suffered a traumatic brain injury has his blood pressure increase from 130/60 to 170/65 mm Hg. The nurse should respond to this increase in blood pressure by: 1. Weighing the patient to determine if the patient is fluid overloaded 2. Documenting the blood pressure and completing a neurologic assessment 3. Alerting the physician and preparing to administer an antihypertensive agent 4. Providing the patient with immediate pain and/or antianxiety medication

2. Documenting the blood pressure and completing a neurologic assessment Correct Answer: 2 Rationale 1: This change in blood pressure is not due fluid volume overload. *Rationale 2: Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. When systemic blood pressure is too high, cerebral vessels constrict and maintain normal cerebral blood flow. When systemic blood pressure is more than 160 mm Hg, and when cerebral perfusion drops below a minimum level, autoregulation is not effective. The nurse needs to assess the impact of the increased blood pressure on the patient's neurologic status by completing a neurologic assessment. * Rationale 3: The nurse would need to assess the patient's neurologic status before contacting the physician for treatment. Rationale 4: The nurse needs to first assess the patient's neurologic status before medicating for pain or anxiety since these types of medications will dampen neurologic responses.

Under the F section of the assessment process, in addition to full vital signs, the family is considered as a part of the treatment process. Which approach to the family would be most appropriate for the nurse to use? 1. The family gets in the way of acute care management so the nurse should offer no support until the patient is stable. 2. Ethically the family has a right to support the patient by being at the bedside during acute care management, including trauma resuscitation. 3. Depending on the family's awareness of health care management, they have the privilege to watch the care if they do not get in the way of the care. 4. Because the care during trauma management can be too graphic for family to witness, the family should not be allowed at the bedside.

2. Ethically the family has a right to support the patient by being at the bedside during acute care management, including trauma resuscitation. Correct Answer: 2 Rationale 1: This is a bias and it has been shown that having family at the bedside to support the patient will frequently give a better outcome. *Rationale 2: Legally and ethically the family has the right to be with the patient under all circumstances, including trauma resuscitation. This topic is greatly debated but the right is still present and often left to the physician to decide if the family should step out. * Rationale 3: With or without the medical/health care background, the right is still present and it is not a privilege to be awarded by staff. Rationale 4: Even if the circumstance is graphic for the family, the right is present and benefits will be gained by the patient. The focus of care is not the family's needs first but the patient's.

A patient's mean arterial pressure (MAP) decreases to 50 while his ICP is 20. The nurse realizes that this drop in MAP is likely to lead to: 1. Increased intracranial pressure 2. Hypoxic cerebral tissue 3. Increased urine output 4. Bradycardia

2. Hypoxic cerebral tissue Correct Answer: 2 Rationale 1: A decline in mean arterial pressure is not going to cause an increase in intracranial pressure. *Rationale 2: Cerebral perfusion is dependent on the blood pressure and the intracranial pressure. It is the difference between the pressure of the incoming blood or MAP and the force opposing perfusion of the brain, or the intracranial pressure. Normal values for cerebral perfusion pressure should be greater than 50 to 60. A pressure less than 40 to 50 usually results in the loss of autoregulation and leads to hypoxia of cerebral tissue.* Rationale 3: A decline in mean arterial pressure is not going to cause an increase in urine output. Rationale 4: A decline in mean arterial pressure is not going to cause bradycardia.

When discussing hemorrhagic shock with a nursing class, which statement by a student indicates to the nurse educator that additional teaching is required? 1. Blood loss into the abdominal cavity can lead to hypovolemic shock. 2. Septic shock is more common than hemorrhagic shock due to nosocomial infections. 3. When fluids shift into the interstitial spaces, the loss of vascular fluids can lead to hypovolemic shock. 4. Hemorrhagic shock symptoms include tachycardia, dyspnea, and hypotension.

2. Septic shock is more common than hemorrhagic shock due to nosocomial infections. Correct Answer: 2 Rationale 1: This is a true statement and does not need additional teaching. *Rationale 2: Septic shock is not more common than hemorrhagic shock. Hemorrhage is the most common cause for shock. * Rationale 3: This is a true statement and does not need additional teaching. Rationale 4: This is a true statement and does not need additional teaching.

When providing care to a patient with increased intracranial pressure, the nurse would be concerned about which clinical finding because it can result in an additional increase in intracranial pressure? 1. Temperature of 99°F (37.2°C) 2. Respiratory rate of 24 3. Serum sodium of 110 mEq/L 4. Blood pressure of 150/65

3. Serum sodium of 110 mEq/L Correct Answer: 3 Rationale 1: This is a minor temperature elevation and would not contribute to the patient's increased intracranial pressure. Rationale 2: This is a minor respiratory rate increase and would not contribute to the patient's increased intracranial pressure. *Rationale 3: Hyponatremia is considered a secondary cause that contributes to increases in intracranial pressure. This laboratory value should be reported and treatment started to avoid additional pressure increases. * Rationale 4: This blood pressure is within parameters that would not affect the patient's cerebral perfusion and is unlikely to contribute to the patient's increased intracranial pressure.

Which goal would receive the highest priority when caring for the patient with a cervical spine injury? 1. Relieve muscle spasm pain 2. Maintain cervical alignment 3. Support respiratory effort and prevent atelectasis 4. Promote hypothermia

3. Support respiratory effort and prevent atelectasis Correct Answer: 3 Rationale 1: Pain relief is not of the highest priority at this time. Rationale 2: Cervical alignment is not of the highest priority at this time. *Rationale 3: Due to the risk of airway obstruction and damage to nerves that stimulate respiratory function, ventilation may need to be controlled or assisted. Maintaining oxygenation is the priority at this time.* Rationale 4: Promoting hypothermia is not of the highest priority at this time.

What activities would the nurse implement under the A section of assessment priorities when admitting a trauma patient with a suspected spinal cord injury? 1. Using a manual ventilation bag 2. Applying heated blankets 3. Using the jaw thrust maneuver 4. Assessing for history of asthma

3. Using the jaw thrust maneuver Correct Answer: 3 Rationale 1: This action would be seen in step B-Breathing. Rationale 2: This action would be seen in step E-Environment/exposure. *Rationale 3: Airway is covered under the A section. Maintaining an open airway is the first priority. With a fracture or trauma to the neck, respirations may be altered or prevented by bone or tissue misalignment. The jaw thrust maneuver is the correct way to open the airway for a cervical spine injury. * Rationale 4: This action is performed in step H-Head-to-toe assessment/medical history.

Under what circumstance would the nurse expect to prepare a patient for surgery when abdominal trauma has occurred? A patient with: 1. A suspected splenic injury and who has received 1 unit of blood 2. A Grade III liver injury with stable vital signs 3. A contusion to the kidney with a stable H & H 4. A pelvic fracture with muscle rigidity of the abdominal wall

4. A pelvic fracture with muscle rigidity of the abdominal wall Correct Answer: 4 Rationale 1: If additional bleeding requires more than 2 units of blood or becomes unstable, the patient with splenic injury will require surgical repair to stop the bleeding. Rationale 2: In a Grade III liver injury, conservative management outweighs the risks of surgery. If a Grade IV or V injury occurs in the liver, then surgical repair is called for immediately. Rationale 3: With a contusion to the kidney bedrest and careful assessment of renal status is enough for the contusion to resolve with time. *Rationale 4: The patient with a pelvic fracture is exhibiting signs of bladder rupture by the muscle rigidity. Immediate surgery is required to assess and repair the damage to internal organs.*

The nurse is preparing to conduct an hourly neurologic assessment on a patient in the intensive care unit. What is included in this assessment? 1. ECG 2. Brainstem functioning 3. Reflexes 4. Level of consciousness

4. Level of consciousness Correct Answer: 4 Rationale 1: An electrocardiogram is not a part of an hourly neurologic assessment. Rationale 2: On occasion, the nurse might be involved with assessing brainstem functioning; however, this is not a part of an hourly neurologic assessment. Rationale 3: Reflexes are not a part of an hourly neurologic assessment. *Rationale 4: Components of an hourly neurologic assessment usually include, at least, the Glasgow Coma Scale or another assessment of level of consciousness, pupillary response to light, motor function, and vital signs. Assessment of cranial nerves, reflexes, and sensation may be added if indicated. On occasion, the nurse might be involved with assessing brainstem functioning.*

Hypovolemic shock that results from an internal shifting of fluid from the intravascular space to the extravascular space is known as a. absolute hypovolemia. b. distributive hypovolemia. c. relative hypovolemia. d. compensatory hypovolemia.

ANS: C Hypovolemia results in a loss of circulating fluid volume. A decrease in circulating volume leads to a decrease in venous return, which results in a decrease in end-diastolic volume or preload..

The mother of a patient just admitted with a spinal cord injury is asking if the patient will be given steroids. What would be an accurate way for the nurse to explain the role of steroids in treating spinal cord injuries? 1. Steroids will make the patient feel better overall and retain muscle strength due to its "muscle-bulking" effects. 2. Steroids have few side effects and remove all symptoms while healing the problem. 3. Steroids can lead to "road-rage and anger outbursts" and therefore are avoided except under extreme emergencies. 4. Steroids limit spinal cord edema and ischemia if initiated within 3 hours of the trauma and given for 48 hours.

4. Steroids limit spinal cord edema and ischemia if initiated within 3 hours of the trauma and given for 48 hours. Correct Answer: 4 Rationale 1: This is not the reason for using steroids in the patient with a spinal cord injury. Rationale 2: These drugs do have some major side effects such as hyperglycemia, hypertension, redistribution of fat pads, and edema, as well as others that can be life threatening. Rationale 3: This is not a concern for the patient with a spinal cord injury. *Rationale 4: This is due to the anti-inflammatory effect of steroid therapy and would be the best response for the nurse to make.*

The main cause of cardiogenic shock is a. an inability of the heart to pump blood forward. b. hypovolemia, resulting in decreased stroke volume. c. disruption of the conduction system when re-entry phenomenon occurs. d. an inability of the heart to respond to inotropic agents.

ANS: A Cardiogenic shock is the result of failure of the heart to effectively pump blood forward. It can occur with dysfunction of the right or the left ventricle or both. The lack of adequate pumping function leads to decreased tissue perfusion and circulatory failure.

When opening the airway of an unresponsive trauma patient in the emergency department, which of the following considerations is correct? a. Airway assessment must incorporate cervical spine immobilization. b. Hyperextension of the neck is the only acceptable technique. c. Flexion of the neck protects the patient from further injury. d. Airway patency takes priority over cervical spine immobilization.

ANS: A Airway assessment must incorporate cervical spine immobilization. The patient's head should not be rotated, hyperflexed, or hyperextended to establish and maintain an airway. The cervical spine must be immobilized in all trauma patients until a cervical spinal cord injury has been definitively ruled out.

A patient who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distention, tracheal deviation to the left, and decreased breath sounds on the right side. What is the most likely diagnosis? a. Tension pneumothorax b. Cardiac tamponade c. Simple pneumothorax d. Ruptured diaphragm

ANS: A Clinical manifestations of a tension pneumothorax include dyspnea, tachycardia, hypotension, and sudden chest pain extending to the shoulders. Patients with cardiac tamponade will not have unilateral decreased breath sounds. Neither a simple pneumothorax nor a ruptured diaphragm will result in hypotension, jugular venous distention, or tracheal deviation unless it goes untreated.

A patient has sustained an epidural hematoma after a 10-foot fall from a roof. Which of the following is true about epidural hematomas? a. They are usually arterial in nature. b. They typically have a worse mortality rate than subdural hematomas. c. They are associated with a permanent loss of consciousness. d. Clinical signs and symptoms include bilateral pupil dilation.

ANS: A Epidural hematoma (EDH) is a collection of blood between the inner table of the skull and the outermost layer of the dura. EDHs are most often associated with skull fractures and middle meningeal artery lacerations (two thirds of patients). A blow to the head that causes a linear skull fracture on the lateral surface of the head may tear the middle meningeal artery. As the artery bleeds, it pulls the dura away from the skull, creating a pouch that expands into the intracranial space.

The nursing measure that can best enhance large volumes of fluid replacement in hypovolemic shock is a. insertion of a large-diameter peripheral intravenous catheter. b. positioning the patient in the Trendelenburg position. c. forcing at least 240 mL of fluid each hour. d. administering intravenous lines under pressure.

ANS: A Measures to facilitate the administration of volume replacement include insertion of large-bore peripheral intravenous catheters; rapid administration of prescribed fluids; and positioning the patient with the legs elevated, trunk flat, and head and shoulders above the chest.

During assessment of a patient who is new to the critical unit, the nurse observes perianal ecchymosis. The nurse suspects the patient has a a. pelvic fracture. b. bladder trauma. c. rectal laceration. d. spleen laceration.

ANS: A Signs of pelvic fracture include perianal ecchymosis (scrotum or vulva) indicating extravasation of urine or blood, pain on palpation or "rocking" of the iliac crests, lower limb paresis or hypesthesia, and hematuria. A large percentage of bladder injuries result from pelvic fractures. Physical findings may include lower abdominal bruising, distention, and pain. More definitive findings include difficulty in voiding or incomplete recovery of irrigation fluids from catheterized patients.

Signs and symptoms of compartment syndrome in the lower extremities include (Select all that apply.) a. paresis. b. increased pain. c. pain in the affected extremity. d. swelling in the affected extremity. e. decrease pulses and capillary refill. f. increase urinary output.

ANS: A, B, C, D Clinical manifestations of compartment syndrome include obvious swelling and tightness of an extremity, paresis, and pain of the affected extremity. Diminished pulses and decreased capillary refill do not reliably identify compartment syndrome because they may be intact until after irreversible changes have occurred. Elevated intracompartmental pressures confirm the diagnosis.

Clinical manifestations of abdominal compartment syndrome include which of the following? (Select all that apply.) a. Decreased cardiac output b. Decreased peripheral vascular resistance c. Decreased urine output d. Hypoxia e. Bradycardia f. Hypotension

ANS: A, C, D, F Increased abdominal cavity pressure can impinge on diaphragmatic excursion and can affect ventilation. Clinical manifestations of abdominal compartment syndrome include decreased cardiac output, increased pulmonary vascular resistance, increased peak pulmonary pressures, decreased urine output, and hypoxia.

A patient's condition has deteriorated. Changes in condition include trachea shift, absence of breath sounds on the left side, and hypotension. The nurse suspects that the patient has developed a(n) a. cardiac tamponade. b. hemothorax. c. open pneumothorax . d. ruptured diaphragm.

ANS: B Assessment findings for patients with a hemothorax include hypovolemic shock. Breath sounds may be diminished or absent over the affected lung. With hemothorax, the neck veins are collapsed, and the trachea is at midline. Massive hemothorax can be diagnosed on the basis of clinical manifestations of hypotension associated with the absence of breath sounds or dullness to percussion on one side of the chest.

Motor vehicle crashes (MVCs) and falls are the greatest cause of a. spinal shock. b. blunt thoracic trauma. c. maxillofacial injuries d. penetrating thoracic injuries.

ANS: B Blunt trauma to the chest most often is caused by MVCs or falls. Spinal shock is a condition that can occur shortly after traumatic injury to the spinal cord. Maxillofacial injury results from blunt or penetrating trauma. Blunt trauma may occur from motor vehicle, industrial, or athletic injuries; violent blows to the head; or falls. The penetrating object involved determines the damage sustained from penetrating thoracic trauma. Low-velocity weapons (e.g., .22-caliber gun, knife) usually damage only what is in the weapon's direct path.

Shock syndrome can best be described as a a. physiologic state resulting in hypotension and tachycardia. b. generalized systemic response to inadequate tissue perfusion. c. degenerative condition leading to death. d. condition occurring with hypovolemia that results in irreversible hypotension.

ANS: B Shock is a complex pathophysiologic process that often results in multiple organ dysfunction syndrome and death. All types of shock eventually result in ineffective tissue perfusion and the development of acute circulatory failure.

Signs of hypovolemia in the trauma patient include a. distended neck veins. b. a decreased level of consciousness. c. bounding radial and pedal pulses. d. a widening pulse pressure.

ANS: B Signs of underperfusion include flattened neck veins, a decreased level of consciousness, weak and thready peripheral pulses, and a narrowed pulse pressure.

Which medication is not recommended in the treatment of shock-related lactic acidosis? a. Glucose b. Sodium bicarbonate c. V asoconstrictor d. Large quantity of crystalloids fluids

ANS: B Sodium bicarbonate is not recommended in the treatment of shock-related lactic acidosis. Glucose control to a target level of 140 to 180 mg/dL is recommended for all critically ill patients. Vasoconstrictor agents are used to increase afterload by increasing the systemic vascular resistance and improving the patient's blood pressure level. Crystalloids are balanced electrolyte solutions that may be hypotonic, isotonic, or hypertonic. Examples of crystalloid solutions used in shock situations are normal saline and lactated Ringer solution.

The patients at highest risk for neurogenic shock are those who have had a. a stroke. b. a spinal cord injury. c. Guillain-Barré syndrome. d. a craniotomy.

ANS: B The most common cause is spinal cord injury (SCI). Neurogenic shock may mistakenly be referred to as spinal shock. The latter condition refers to loss of neurologic activity below the level of SCI, but it does not necessarily involve ineffective tissue perfusion.

Which of the following statements is true about a patient with a blunt cardiac injury/cardiac contusion? a. It will probably be diagnosed by pericardiocentesis. b. Hemodynamic parameters will most likely show a low cardiac output and low systemic vascular resistance. c. Treatment can require insertion of a temporary pacemaker for conduction control. d. The only accurate way to evaluate cardiac contusion is to check the creatine phosphokinase fraction.

ANS: C Medical management is aimed at preventing and treating complications. This approach may include administration of antidysrhythmic medications, treatment of heart failure, or insertion of a temporary pacemaker to control conduction abnormalities. Assessment of fluid and electrolyte balance is imperative to ensure adequate cardiac output and myocardial conduction.

The majority of falls accounting for traumatic injury occur in what population? a. Construction workers b. Adolescents c. Older adults d. Young adults

ANS: C Older persons experience most of the falls that result in injuries, and these falls are likely to occur from level surfaces or steps. Because many of the falls may be caused by an underlying medical condition (e.g., syncope, myocardial infarction, dysrhythmias), management of an older patient who has fallen must include an evaluation of events and conditions immediately preceding the fall.

The nursing care plan of a patient with a diffuse axonal injury (DAI) would involve which of the following considerations? a. Neurologic assessments should be performed only once a shift. b. The patient will need a computed tomography scan for definitive diagnosis of the injury. c. Blood pressure and temperature elevations are common. d. The patient is at risk for volume overload because of syndrome of inappropriate antidiuretic hormone.

ANS: C The pathophysiology of DAI is related to the stretching and tearing of axons as a result of movement of the brain inside the cranium at the time of impact. The stretching and tearing of axons result in microscopic lesions throughout the brain, but especially deep within cerebral tissue and the base of the cerebrum. Disruption of axonal transmission of impulses results in loss of consciousness. Unless surrounding tissue areas are significantly injured, causing small hemorrhages, DAI may not be visible on computed tomography or magnetic resonance imaging. DAI can be classified as one of three grades based on the extent of lesions: mild, moderate, or severe. Severe DAI usually manifests as a prolonged, deep coma with periods of hypertension, hyperthermia, and excessive sweating. Treatment of DAI includes support of vital functions and maintenance of intracranial pressure within normal limits. The outcome after severe DAI is poor because of the extensive dysfunction of cerebral pathways.

Signs and symptoms associated with a flail chest include a. tracheal deviation toward the unaffected side. b. jugular venous distention. c. paradoxical respiratory movement. d. respiratory alkalosis.

ANS: C Tracheal deviation and jugular venous distention are findings associated with tension pneumothorax. Respiratory acidosis is usually present because of the ineffective breathing pattern. In a flail chest, a free-floating segment of the chest wall moves independently from the rest of the thorax and results in paradoxical chest wall movement during the respiratory cycle. During inspiration, the intact portion of the chest wall expands while the injured part is sucked in. During expiration, the chest wall moves in, and the flail segment moves out.

Which of the following will cause a nurse to suspect that a patient's pulmonary contusion is worsening? a. A pulmonary artery catheter showing a central venous pressure of 6 cm H2O and a wedge pressure of 8 mm Hg b. An increased need for pain medication c. An arterial blood gas value that demonstrates respiratory alkalosis d. Increased peak airway pressures on the ventilator

ANS: D A contusion manifests initially as a hemorrhage followed by alveolar and interstitial edema. The edema can remain rather localized in the contused area or can spread to other lung areas. Inflammation affects alveolar-capillary units. As more units are affected by inflammation, further pathophysiologic events can occur, including decreased compliance, increased pulmonary vascular resistance, and decreased pulmonary blood flow. These processes result in a ventilation-perfusion imbalance that results in progressive hypoxemia and poor ventilation over a 24- to 48-hour period.

Which of the following hemodynamic parameters supports the diagnosis of cardiogenic shock? a. Increased right atrial pressure b. Decreased pulmonary artery wedge pressure c. Increased cardiac output d. Decreased cardiac index

ANS: D Assessment of the hemodynamic parameter of patients in cardiogenic shock reveals a decreased cardiac output and a cardiac index less than 2.2 L/min/m2.

The most important aspect of a secondary survey is to a. check circulatory status. b. check electrolyte profile. c. insert a urinary catheter. d. obtain patient history.

ANS: D During the secondary survey, a head-to-toe approach is used to thoroughly examine each body region. The history is one of the most important aspects of the secondary survey. Additional interventions during the resuscitation phase involve placement of urinary and gastric catheters. During resuscitation from traumatic hemorrhagic shock, normalization of standard clinical parameters such as blood pressure, heart rate, and urine output are not adequate. Circulatory status is part of the primary survey.

Which of the following physiologic changes caused by aging is the most likely contributor to the high mortality rate in older trauma patients compared with younger trauma patients? a. Deterioration of cerebral and motor skills b. Poor vision and hearing c. Diminished pain perception d. Limited cardiovascular physiologic reserve in the elderly

ANS: D Older adults have limited ability to increase their heart rate in response to blood loss, obscuring one of the earliest signs of hypovolemia—tachycardia. Loss of physiologic reserve and the presence of pre-existing medical conditions are likely to produce further conflicting hemodynamic data. An older patient's lack of physiologic reserve makes it imperative that early nutritional support is initiated.

A strategy to minimize secondary brain injury in head-injured patients is a. hyperventilation to keep PCO2 less than 30. b. fluid restriction to keep central venous pressure less than 6 cm H2O. c. maintaining body temperature more than 37.5° C. d. fluid resuscitation as needed to keep the systolic blood pressure greater than 90 mm Hg.

ANS: D Secondary injury can be caused by ischemia, hypercapnia, hypotension, cerebral edema, sustained hypertension, calcium toxicity, or metabolic derangements. Hypoxia or hypotension, the best known culprits for secondary injury, typically are the result of extracranial trauma. Extreme vasodilation of the cerebral vasculature occurs in an attempt to supply oxygen to the cerebral tissue. This increase in blood volume increases intracranial volume and raises intracranial pressure.