Trauma

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. which of the following assessments should take the highest priority to perform

A Deviated trachea

Which patient should the nurse priories as needing emergent treatment assuming no other injuries present except the ones outlined below

A patient with a blunt chest trauma with some difficulty breathing

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey

Brief neurologic assessment

You respond to a call for help from the ED waiting room. there is an elderly patient lying on the floor.

1 establish unresponsiveness 2 call for help and activate the code team 3 perform the chin lift or jaw thrust maneuver 4 initiate CPR 5 instruct a nursing assestant to het the crash cart

A trauma cleitn with multiple open wounds is brought to the emergency department in cardiac arrest. which action should the nurse take prior to providing advanced cardiac slife support

Don personal protective equipment

A client was brought to the emergency department after suffering a closed head injury and laceration around the face due to a hit-run accident. the client is unconscious and has a minimal responses to noxious stimuli which of the following assessment findings if observed after a few hours should be reported to the physician immediately

Drainage of a clear fluid from the clients nose

Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus

acute respiratory distress syndrome

A client with a subdural hematoma becomes restless with confused, with dilation of the ipsilateral pupil. the physician orders mannitol for which of the following reasons

To promote osmotic diuresis to decrease ICP

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. the nurse assessment reveals a blood pressure of 90/50mmhg a pulse rate of 100 beats/min and urine output of 20ml over the past hour. the nurse reports the findings to the physician and antipastes which of the following orders to be prescribed

increasing the amount of IV lactated ringers administered per hour

The nurse is assessing the motor function of an unconscious client. the nurse would plan to use which of the following to test the clients peripheral response to pain

nail bed pressure

A nurse has conducted teaching with a client in an arm cast about signs and symptoms of compartment syndrome. The nurse determines that the client understand the information if the client states that he or she should report which of the following early symptoms of compartment syndrome.

numbness and tingling in the fingers

The major preventable cause of death in the trauma patient is:

uncontrolled hemorrhage

The adult client was burned as a result of an explosion, the burn initially affected the clients entire face and the upper half of the anterior torso and there were circumferential burns to the lower half of both arms. the clients clothes caught on fire and the client ran causing subsequent burn injuries to the posterior surface of the head and upper half of the posterior torso.

36

A client with trauma to the chest develops a tension pneumothorax. After needle thoracostomy is performed the nurse would expect

An increase in blood pressure

A 15 year old has been brought to the emergency department by his friends after serving his brachial artery while trying to scale a fance. In order to stop this patents bleeding, the nurse should

Apply direct pressure to the wound

What is the first step to stop a hemorrhage associated with an amputated extremity

Apply tourniquet

A trauma patient in the emergency department is showing signs of acute renal failure that the care team suspects are due to myoglobinuria. the ED nurse should recognize that these problems are most closely associated with what type of injury

Crush injury

A patient is brought by friends to the ED after being

Immobilize the patient on a backboard

A patient is diagnosed with a small subdural hematoma with a history of a trip and fall in which he hit his head on the sink two days ago. He is waiting for an inpatient bed. the nursing shift reports indicates that he did not sleep last night and has been very anxious as the nurse begins an assessment, he vomits and states he couldn't sleep because young children kept coming into his room during the night. What is a likely cause of these signs and symptoms?

Increased intracranial pressure

An intubated patient is being transferred to the ICU after a motor vehicle crash. He received aggressive fluid resuscitation. results of an FAST exam in the emergency department were negative. Assessment at this time reveals marked abdominal distention, oliguria, and significant tachycardia with hypotension. Investigating the most likely etiology the nurse would expect to obtain

Renal ultrasound

A nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a 3rd-degree circumferential arm burn. the nurse understands that the anticipated outcome of the escharotomy is

Return of distal pulses

A client was a C4 spinal injury would most likely have which of the following symptoms

Tetraplegia

A clients presents in the emergency department after falling from a roof. A fracture of the femoral neck suspected. Which of these assessments best supports this diagnosis

The affected extremity is shortened, adducted and extremely rotated

A young male patient has been brought to the emergency department with a knife wound to the abdomen. when the patient's hands are removed from the area of the wound to facilitate assessment, the patients intestine protrudes from the wound. How should the nurse respond to the development

cover the protruding viscera with saline soaked, sterile gauze

Which of the following findings on initial assessment is a late manifestation of a tension pneumothorax

cyanosis