Urden Critical Care Chapter 24- Trauma

Chapter 24: Trauma Urden: Priorities in Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. An unresponsive trauma patient has been admitted to the emergency department. Which statement regarding opening the airway is accurate? 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. PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

8. 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. The nurse suspects these findings are indicative of which disorder? 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. PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. A patient has sustained an epidural hematoma after a 10-foot fall from a roof. The nurse understands that an epidural hematoma is a condition that has which characteristic? a. Most often associated with middle meningeal artery lacerations b. Collection of blood between the dura mater and the arachnoid membrane c. Associated with a permanent loss of consciousness d. 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). The classic clinical manifestations of EDH include brief loss of consciousness followed by a period of lucidity. Rapid deterioration in the level of consciousness should be anticipated, because arterial bleeding into the epidural space can occur quickly. The patient may complain of a severe, localized headache and may be sleepy. A dilated and fixed pupil on the same side as the impact area is a hallmark of EDH. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation

10. A patient is admitted with acute abdominal trauma. The patient has a positive Focused Assessment with Sonography for Trauma (FAST scan) and is hemodynamically unstable. What procedure should the nurse anticipate next? a. Emergency surgery b. Diagnostic peritoneal lavage (DPL) c. Computed tomography scan d. Intra-abdominal pressure monitoring

ANS: A Hemodynamically unstable patients with a positive FAST scan generally undergo emergency surgery to achieve hemostasis. Diagnostic peritoneal lavage (DPL) is undertaken less frequently in many trauma centers. CT scanning is the mainstay of diagnostic evaluation in the hemodynamically stable patient with abdominal trauma; however, when the patient is hemodynamically unstable, the patient is taken to surgery. Intraabdominal pressure monitoring is done in the presence of intra-abdominal hypertension. PTS: 1 DIF: Cognitive L vel: Applying OBJ: Nursing Process Step: Planning TOP: Trauma

12. A patient with multisystem trauma has been in the ICU for 6 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The patient's vital signs include: BP— 92/66 mm Hg; HR—118 beats/min; T—38.7°C; and CVP—5 mm Hg. What is the most likely cause of this hemodynamic picture? a. Septic shock b. Hemorrhagic shock c. Cardiogenic shock d. Neurogenic shock

ANS: A The patient with multiple injuries is at risk for overwhelming infections and sepsis. The source of sepsis in the trauma patient can be invasive therapeutic and diagnostic catheters or wound contamination with exogenous or endogenous bacteria. The source of the septic nidus must be promptly evaluated. Gram stain and cultures of blood, urine, sputum, invasive catheters, and wounds are obtained. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation

19. A patient developed a hemothorax after a blunt chest trauma. The practitioner inserted a chest tube on the left side and 1800 mL of blood was evacuated from the chest. The nurse expects that the patient will be taken to surgery for what procedure? a. Thoracotomy b. Pericardiocentesis c. Splenectomy d. Pneumonectomy

ANS: A Thoracotomy may be necessary for patients who require persistent blood transfusions or who have significant bleeding (200 mL/hr for 2 to 4 hours or more than 1500 mL on initial tube insertion) or when there are injuries to major cardiovascular structures. PTS: 1 DIF: Cognitive L vel: Applying OBJ: Nursing Process Step: Planning TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

4. The nurse is caring for a patient with blunt abdominal trauma. The nurse understands that patient is at risk for abdominal compartment syndrome. Which findings would the nurse expect to observe as evidence of this complication? (Select all that apply.) a. Decreased cardiac output b. Increased peak pulmonary pressures c. Decreased urine output d. Hypoxemia e. Bradycardia

ANS: A, B, C, D Clinical manifestations of abdominal compartment syndrome include decreased cardiac output, decreased tidal volumes, increased peak pulmonary pressures, decreased urine output, and hypoxemia. PTS: 1 DIF: Cognitive Le el: Analyzing OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

2. A patient has been admitted with muscle trauma and crush injuries. The nurse understands that this patient is at high risk for the development of acute kidney injury secondary to rhabdomyolysis. Which findings would suggest the patient is developing this complication? (Select all that apply.) a. Dark tea-color urine b. Decreased urine output c. Decreased oxygen saturation d. Diminished pulses e. Increased serum creatine kinase level

ANS: A, B, E Circulating myoglobin can lead to the development of acute kidney injury by three mechanisms: decreased renal perfusion, cast formation with tubular obstruction, and direct toxic effects of myoglobin in the kidney tubules. Dark tea-colored urine suggests myoglobinuria. The most rapid screening test is a serum creatine kinase level. Urine output and serial creatine kinase levels should be monitored. Decreased oxygen saturation and diminished pulses are not associated with rhabdomyolysis. PTS: 1 DIF: Cognitive Le el: Analyzing OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

5. Patients immobilized because of spinal trauma are at a high risk for contractures. The nursing management plan for these patients should include which preventive measures? (Select all that apply.) a. Consultation by PT and OT early in the treatment of the patient b. Turning and repositioning the patient every 2 hours as ordered by the practitioner c. Range of motion exercises 1 month after the spine has been stabilized d. Removal of splints every 4 hours and at bedtime e. Hand splints for patients with paraplegia f. Hand and foot splints for patients with quadriplegia

ANS: A, B, F Physical therapy and occupational therapy personnel should be consulted early in the patient's course. Range of motion exercises are initiated as soon as the spine has been stabilized. Foot drop splints should be applied on admission to prevent contractures and prevent skin breakdown of the heels. Hand splints should be applied for patients with quadriplegia. Hand and foot splints should be removed every 2 hours.

3. The nurse is caring for a patient with extensive trauma to the lower extremities. The nurse understands that patient is at risk for compartment syndrome. Which findings would the nurse expect to observe as evidence of this complication? (Select all that apply.) a. Paresthesia b. Decreased pulses c. Pain in the affected extremity d. Swelling in the affected extremity e. Decreases capillary refill

ANS: A, C, D Clinical manifestations of compartment syndrome include obvious swelling and tightness of an extremity, paresthesia, 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. PTS: 1 DIF: Cognitive Le el: Analyzing OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE 1. Major trauma patients are at high risk of developing deep venous thrombosis and pulmonary embolism. The nurse understands that trauma patients are at risk due to which factors? (Select all that apply.) a. Blood stasis b. Hypernatremia c. Injury to the intimal surface of the vessel d. Hyperosmolarity e. Hypercoagulopathy f. Immobility

ANS: A, C, E, F The factors that form the basis of venous thromboembolism pathophysiology are blood stasis, injury to the intimal surface of the vessel, and hypercoagulopathy. Trauma patients are at risk for VTE because of endothelial injury, coagulopathy, and immobility. Hypernatremia and hyperosmolarity are associated with acute kidney injury. PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. A trauma patient's condition has deteriorated. The nurse observes changes in the patient's condition including trachea shift, absence of breath sounds on the left side, and hypotension. The nurse suspects that the patient has developed what complication? 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. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. A patient is admitted to the ICU for observation of his grade II splenic laceration. Which signs and symptoms suggest that the patient has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock? a. BP, 110/70 mm Hg; HR, 120 beats/min; Hct, 42 mg/dL; UO, 40 mL/hr; skin that is pink, warm, and dry with capillary refill of 3 seconds b. BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/hr; pale, cool, clammy skin; confused c. BP, 100/60 mm Hg; HR, 100 beats/min; Hct, 35 mg/dL; UO, 30 mL/hr; pale, cool, dry skin; alert and oriented d. BP, 110/60 mm Hg; HR, 118 beats/min; Hct, 38 mg/dL; UO, 60 mL/hr; flushed, warm, diaphoretic skin; agitated and confused

ANS: B The first set of vital signs is normal. Patients who are in hemorrhagic shock are significantly tachycardic with a narrowed pulse pressure and oliguric, and their skin is pale, cool, and clammy. They also have a low hematocrit and are confused. Hemodynamically stable patients may be monitored in the critical care unit by means of serial hematocrit values and vital signs. Progressive deterioration may indicate the need for operative management. PTS: 1 DIF: Cognitive Le el: Analyzing OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. A patient is admitted with a blunt cardiac injury (BCI) with no evidence of rupture. The nursing management plan should include which intervention? a. Administer nitroglycerine for chest pain as needed. b. Monitor the patient for new onset dysrhythmias. c. Monitor serial biomarkers for evidence of further damage. d. Do not administer antidysrhythmic medications as they are ineffective.

ANS: B The patient should be monitored for new onset of dysrhythmias. The patient may complain of chest pain that is similar to anginal pain, but it is not typically relieved with nitroglycerin. Chest pain is usually caused by associated injuries. Use of biomarkers, such as troponin, offers very little diagnostic help for BCI. Medical management is aimed at preventing and treating complications. This approach includes hemodynamic monitoring in a critical care unit and possible administration of antidysrhythmic medications. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Trauma

20. The nurse understands that certain trauma patients are at risk for developing fat embolism syndrome. Which type of trauma is this complication usually associated with? a. Liver trauma b. Kidney trauma c. Orthopedic trauma d. Spinal cord trauma

ANS: C Fat embolism syndrome can occur as a complication of orthopedic trauma. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. The nurse is working on an organization-wide falls prevention project. The nurse understands that 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. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological InGteRgrAitDy:EPShyMsiOolRoEgic.aCl AOdMaptation

15. A patient with multisystem trauma has been in the critical care unit for 2 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The nurse understands that immobility places the patient at risk for developing which complication? a. Hypovolemic shock b. Acute kidney injury c. Venous thromboembolism d. Malnutrition

ANS: C Patients with major trauma are at very high risk for VTE. Factors that form the basis of VTE pathophysiology are common in trauma, including endothelial injury (as a result of trauma), hypercoagulopathy (as a result of trauma-induced coagulopathy), and blood stasis (as a result of immobility). The patient should have already been treated for hypovolemic shock. While the patient is at risk for acute kidney injury and malnutrition but not from immobility. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

4. A patient is admitted with a severe diffuse axonal injury (DAI) secondary to a motor vehicle crash. The patient's plan of care would involve which nursing action? a. Perform neurologic assessments once a shift. b. Obtain a computed tomography (CT) scan every day. c. Monitor blood pressure and temperature every hour. d. Initiate warming measures to keep temperature greater than 37.5°C.

ANS: C Severe DAI usually manifests as a prolonged, deep coma with periods of hypertension, hyperthermia, and excessive diaphoresis. Treatment of DAI includes support of vital functions. Neurologic assessment is performed every hour. DAI may not be visible on CT scan. Warming measures are generally not needed but cooling measure may be needed. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

6. A patient has been admitted with a flail chest. What findings would the nurse expect to observe supporting this diagnosis? 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. PTS: 1 DIF: Cognitive Le el: Applying OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. A patient has been admitted with a pulmonary contusion. Which finding will cause a nurse to suspect that the patient's condition is deteriorating? a. Increased bruising on the chest wall b. Increased need for pain medication c. The development of respiratory alkalosis d. Increased work of breathing

ANS: D A contusion manifests initially as a hemorrhage followed by alveolar and interstitial edema. Patients with severe contusions may continue to show decompensation, such as respiratory acidosis and increased work of breathing, despite aggressive nursing management. Increased bruising and the need for pain medication are not signs of deterioration. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Evaluation TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. A patient is admitted with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. The nurse suspects the patient may have which type of injury? a. Posterior cord syndrome b. Brown- Séquard syndrome c. Diffuse axonal injury d. Central cord syndrome

ANS: D Central cord syndrome is associated with cervical hyperextension/flexion injury and hematoma formation in the center of the cervical cord. This injury produces a motor and sensory deficit more pronounced in the upper extremities than in the lower extremities. Posterior cord syndrome is associated with cervical hyperextension injury with damage to the posterior column. This results in the loss of position sense, pressure, and vibration below the level of injury. Brown-Séquard syndrome is associated with damage to only one side of the cord. This produces loss of voluntary motor movement on the same side as the injury, with loss of pain, temperature, and sensation on the opposite side. Diffuse axonal injury (DAI) is a term used to describe prolonged posttraumatic coma that is not caused by a mass lesion, although DAI with mass lesions has been reported. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. A nurse and a new graduate nurse are discussing the secondary survey of the trauma patient. The nurse asks the new graduate to identify the most important aspect of a secondary survey. Which response would indicate the new graduate nurse understood the information? 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. PTS: 1 DIF: Cognitive Le el: Applying OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

2. A patient with severe traumatic brain injury has been admitted to the critical care unit. What is one intervention to minimize secondary brain injury? a. Hyperventilate the patient to keep PCO2 less than 30. b. Restrict fluids to keep central venous pressure less than 6 cm H2O. c. Maintain the patient's body temperature more than 37.5°C. d. Administer fluids to keep the mean arterial pressure greater than 60 mm Hg.

ANS: D Heart rate and blood pressure are continually monitored, with the goal of achieving MAP greater than 60 mm Hg (minimum) to ensure adequate perfusion to the brain. Secondary injury is the biochemical and cellular response to the initial trauma that can exacerbate the primary injury and cause additional damage and impairment in brain recovery. Secondary injury can be caused by ischemia, hypotension, hypercapnia, cerebral edema, or metabolic derangements. Hyperventilation will decrease cerebral blood flow. Restricting fluids will contribute to hypovolemia and subsequently hypotension. Elevating the patient's body temperature will increase the cerebral metabolic rate and contribute to cerebral ischemia. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

13. Older trauma patients have a higher mortality than younger trauma patients. The nurse understands that this fact is probably related to what physiologic change? a. Deterioration of cerebral and motor skills b. Poor vision and hearing c. Diminished pain perception d. Limited physiologic reserve

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 preexisting 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. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. A nurse and a nursing student are discussing management of the trauma patient. The nurse asks the student what the AVPU method is used for during the primary survey. Which response would indicate the new graduate nurse understood the information? a. Used to assess respiratory status b. Used to assess circulatory status c. Used to assess pain status d. Used to assess level of conG scRioAuD snEeS ssMORE.COM

ANS: D The AVPU method can be used to quickly describe the patient's level of consciousness: A: alert, V: responds to verbal stimuli, P: responds to painful stimuli, and U: unresponsive. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Health Promotion and Maintenance