Complications and Special Considerations of Trauma

Which screening tool would the nurse use to evaluate a patient who is suspected of misusing alcohol? PHQ-9 AUDIT CIWA-Ar CIWA-B

AUDIT The Alcohol Use Disorders Identification Test (AUDIT) is an inexpensive, rapid test that has been validated in trauma centers and can be used to screen for problem drinking.

Which intervention would the nurse expect to find on a plan of care to prevent venous thromboembolism (VTE) in a patient recovering from blunt force trauma? Select all that apply. One, some, or all responses may be correct. Administer low-molecular-weight heparin. Routinely monitor fibrinogen levels. Apply sequential compression devices. Implement early mobilization. Infuse intravenous fibrinolytics.

Administer low-molecular-weight heparin. Routine thromboprophylaxis for a high-risk trauma patient includes use of low-molecular-weight heparin. Apply sequential compression devices. Routine thromboprophylaxis for a high-risk trauma patient includes use of a mechanical method of prophylaxis, such as sequential compression devices. Implement early mobilization. Early mobilization can also help prevent development of VTE.

Which parameter would the nurse assess when determining a trauma patient's risk for septic shock? Select all that apply. One, some, or all responses may be correct. Partial thromboplastin time Albumin level Glasgow Coma Scale (GCS) score Injury Severity Score (ISS) Temperature

Albumin level The nurse would assess the albumin level when determining the risk for sepsis. Glasgow Coma Scale (GCS) score The GCS score is incorporated into the scoring when assessing the risk for septic shock and sepsis. Injury Severity Score (ISS) When assessing the risk for septic shock and sepsis, the ISS is incorporated into the scoring. Temperature Temperature and heart rate are important elements to assess when determining risk of sepsis.

When caring for a victim of intimate partner violence (IPV), which intervention would the nurse include in the plan of care? Notify law enforcement. Remove the victim's clothes for assessment. Let the patient know that IPV is a rare event. Assist with development of a safety plan.

Assist with development of a safety plan. The nurse would assist the victim in the development of a safety plan.

When caring for an older adult trauma victim, the nurse would plan to administer additional fluid replacement volume if which condition in the medical history is noted? Pulmonary hypertension Heart failure Chronic kidney disease Spinal cord injury

Chronic kidney disease Older adult patients on long-term diuretic therapy may require additional volume and enhanced potassium supplementation as a result of chronic volume and potassium depletion.

Which intervention would the nurse include in the plan of care for a patient who scored a 17 on the AUDIT assessment tool? Closely monitor for alcohol withdrawal. Provide information on opiate abstinence. Monitor for suicidal behaviors. Administer normal saline.

Closely monitor for alcohol withdrawal. A score greater than 17 indicates alcohol misuse, so the nurse would closely monitor for alcohol withdrawal.

Which condition is characterized by increased pressure within a limited space that compromises circulation? Sepsis Hypermetabolism Compartment syndrome Venous thromboembolism

Compartment syndrome Compartment syndrome is a condition in which increased pressure within a limited space compromises circulation, resulting in ischemia and necrosis of tissues within that space.

Which assessment finding would indicate the development of rhabdomyolysis in a patient with significant musculoskeletal trauma? Dark, tea-colored urine Decreased lactic acid Decreased creatine kinase level Bradycardia

Dark, tea-colored urine Dark, tea-colored urine indicates myoglobinuria, a manifestation of rhabdomyolysis.

After fluid administration in a patient with multiple injuries, which assessment finding would prompt the nurse to assess for a missed injury? Pulmonary infiltrates Decreasing hematocrit level Hypertension Increasing level of consciousness

Decreasing hematocrit level Hypotension and a falling hematocrit level despite fluid administration may indicate new-onset or continued bleeding from missed injury.

Which action would the nurse take to promote the "What Matters" component of the Institute for Healthcare Improvement's (IHI) initiative for care of older adults? Select all that apply. One, some, or all responses may be correct. Discuss end-of-life issues when the patient desires. Implement safety measures if the patient has dementia. Collaborate with the health care provider regarding age-friendly medication. Assign assistive personnel to accompany patient to the restroom. Align care with the patient's specific health outcome goals and preferences.

Discuss end-of-life issues when the patient desires. The "What Matters" component includes knowing and aligning care with each older adult's specific health outcome goals and care preferences, including but not limited to end-of-life care. Align care with the patient's specific health outcome goals and preferences. The "What Matters" component includes knowing and aligning care with each older adult's specific health outcome goals and care preferences.

Which intervention would the nurse use to treat hypermetabolism in a patient admitted to the critical care unit with traumatic injuries? Nasogastric suction Urinary catheter placement Early enteral nutrition Family support

Early enteral nutrition The goal of early nutrition is to maintain host defenses by supporting this hypermetabolism and to preserve lean body mass.

Which symptom is associated with transfusion-related acute lung injury (TRALI)? Select all that apply. One, some, or all responses may be correct. Fever Hypoxemia Hypotension Missed injury Bilateral infiltrates

Fever TRALI may occur 6 hours after a transfusion, as evidenced by fever, hypoxemia, and hypotension. Hypoxemia Hypoxemia is a common manifestation of TRALI. Hypotension A common manifestation of TRALI is hypotension. Bilateral infiltrates Bilateral infiltrates (often described as a "white-out" in clinical practice) may appear on the chest x-ray of a patient with TRALI.

Which factor increases the risk of infection of a traumatic wound with endogenous bacteria? Dirt and grass Microorganisms from wound care Improper personal protective equipment Gastrointestinal perforation

Gastrointestinal perforation Endogenous bacteria (from the internal environment) can be released as a result of gastrointestinal perforation.

Which trauma patient is most at risk for posttraumatic acute kidney injury? History of diabetes that presents with profound alkalosis History of hypertension, hypovolemic shock and rhabdomyolysis History of fibromyalgia and trauma requiring contrast-enhanced computed tomography scan History of chronic kidney disease with decreased intraabdominal pressure

History of hypertension, hypovolemic shock and rhabdomyolysis Rhabdomyolysis, a history of hypertension, and hypovolemic shock all increase the risk of posttraumatic acute kidney injury.

Which factor would increase the risk of falls in older adults? Select all that apply. One, some, or all responses may be correct. Osteoarthritis Syncope Uncontrolled diabetes Use of diuretics Unstable gait

Osteoarthritis Osteoarthritis impairs gait and increases the risk of falls. Syncope Syncope significantly increases the risk of falls. Uncontrolled diabetes The risk of falls is higher for an older adult with a history of diabetes. Use of diuretics The use of diuretics increases the risk of falls. Unstable gait The risk of falls is higher for an older adult with an unstable gait.

Which patient condition places an individual at a higher risk for a missed injury? Select all that apply. One, some, or all responses may be correct. A low ISS Pain requiring analgesia Intoxicated upon admission Restlessness requiring sedation Head injury and a Glasgow Coma Scale score of 12

Pain requiring analgesia A patient with pain requiring analgesia is at an increased risk of missed injury. Intoxicated upon admission A patient that is intoxicated at the time of admission is at an increased risk of missed injury. Restlessness requiring sedation A patient with restlessness that requires sedation for management is at an increased risk of missed injury.

When caring for a patient with spinal cord injury (SCI) and acute respiratory distress syndrome (ARDS), the nurse would question a prescription for which intervention? Mechanical ventilation Positive-end expiratory pressure Low tidal-volume ventilation Prone positioning

Prone positioning Prone positioning is contraindicated in a patient with SCI.

When assessing a patient with orthopedic trauma, the nurse suspects fat embolism syndrome based on which finding? Tachycardia Drowsiness Bradypnea Dark, tarry stools

Tachycardia A patient with a fat embolism will suddenly elevate the heart rate, as the vessel is compromised by the fat lodged in it.