Exam 5 CC Trauma

12. 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

1. 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.

9. 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.

3. 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.

21. 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.

13. A patient with multisystem trauma has been in the ICU for 6 days after sustaining a closed head injury, a right-sided pneumothorax, right rib fractures, a grade IV liver laceration, a pancreatic contusion, and a right acetabular fracture. The patient is still intubated and mechanically ventilated and has a chest tube, Foley catheter, and two abdominal drains. The patient's hemodynamic assessment reveals the following values: BP, 94/66 mm Hg; HR, 118 beats/min; T, 38.7° C; CVP, 5 cm H2O; wedge pressure, 6 mm Hg; cardiac index, 6.1; and systemic vascular resistance, 450 dynes/sec. 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.

20. A patient's condition has deteriorated. Changes in condition include trachea shift, absence of breath sounds on the left side, and hypotension. A chest tube was inserted on the left side with 1800 mL of blood removed. The nurse expects that the patient will be taken to surgery for a a. thoracotomy. b. cardiac tamponade. c. splenectomy. d. pneumothorax.

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

3. 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.

4. 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.

1. Major trauma patients are at a high risk of developing deep venous thrombosis and pulmonary embolism because of (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.

19. 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.

18. 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.

6. A patient is admitted to the ICU with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. Caring for the patient would include which of the following interventions? a. Keeping the room cool, dark, and quiet b. Administering intravenous methylprednisolone for the first 24 hours after the injury c. Elevating the head of the bed 45 degrees d. Resuscitating low blood pressure by only using intravenous fluid

ANS: B Intravenous methylprednisolone controls spinal cord ischemia and swelling, thereby minimizing the extent of tissue damage. The room should be kept warm to avoid hypothermia. Elevating the head of the bed will often cause hypotension and is contraindicated until additional spinal cord injuries have been ruled out. Because of the profound vasodilation found with neurogenic shock, patients should be resuscitated with both intravenous fluids and vasopressors to restore intravascular volume as well as vascular tone.

11. A patient is admitted to the ICU for observation of his grade II splenic laceration. Which of the following signs and symptoms would suggest that he 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.

16. A patient with multisystem trauma has been in the ICU for 6 days after sustaining a closed head injury, a right-sided pneumothorax, right rib fractures, a grade IV liver laceration, a pancreatic contusion, and a right acetabular fracture. The patient is still intubated and mechanically ventilated and has a chest tube, Foley catheter, and two abdominal drains. The patient's hemodynamic assessment reveals the following values: BP, 94/66 mm Hg; HR, 118 beats/min; T, 38.7° C; CVP, 5 cm H2O; wedge pressure, 6 mm Hg; cardiac index, 6.1; and systemic vascular resistance, 450 dyns/sec. The patient is at the greatest risk to develop a. respiratory failure. b. infection. c. venous thromboembolism d. fat embolism syndrome.

ANS: B Trauma patients are at risk for infection because of contaminated wounds, invasive therapeutic and diagnostic catheters, intubation and mechanical ventilation, host susceptibility, and the critical care environment. Nursing management must include interventions to decrease and eliminate the trauma patient's risk of infection

2. Which mechanisms caused by circulating myoglobin can lead to the development of kidney failure? (Select all that apply.) a. Dark tea-color urine b. Decreased renal perfusion c. Cast formation with tubular obstruction d. Administration of diuretics e. Rapid screening for serum creatine kinase level f. Toxic effects of myoglobin in the kidney tubules

ANS: B, C, F Circulating myoglobin can lead to the development of kidney failure 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. Alkalinization of the urine and administration of diuretics have been studied, but their roles in the prevention or management of rhabdomyolysis are not firmly established.

22. 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.

10. 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.

15. 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.

4. 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.

7. 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.

8. 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.

5. A patient is admitted to the ICU with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. Which of the following statements is true about his spinal cord injury? a. He is likely to be in supraventricular tachycardia. b. Hyperthermia is common in patients with spinal cord injury. c. These patients do not usually require mechanical ventilation. d. The patient has a 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.

17. 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.

14. 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.

2. 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.