Trauma-Critical Care

A patient is admitted with trauma to the integumentary system. Which type of skin trauma should the nurse prepare to assess? Standard Text: Select all that apply. 1. cutaneous 2. abrasion 3. laceration 4. contusion 5. keloid

Correct Answer: 2, 3, 4 Rationale 1: Cutaneous is a term used to refer to the integument, not to trauma to the skin. Rationale 2: Abrasions, or partial-thickness denudations of an area of integument, generally result from falls or scrapes. Rationale 3: Lacerations are open wounds that result from sharp cutting or tearing. Rationale 4: Contusions, or superficial tissue injuries, result from blunt trauma that causes the breakage of small blood vessels and bleeding into the surrounding tissue. Rationale 5: A keloid is a type of scar.

Which risk factors could lead to the development of airway failure if not recognized while assessing the airway of a trauma patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: 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

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.

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.

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.

A patient is brought to the emergency department with injuries sustained when a wall collapsed in the home. The nurse recognizes that this patient's injuries were most likely caused by which mechanism of injury? 1. crushing 2. shearing 3. deceleration 4. blast

Correct Answer: 1 Rationale 1: A crushing injury occurs from a high force that leads to tissue destruction. The collapsing wall most likely caused crushing injuries. Rationale 2: Shearing occurs when structures slip across each other. Rationale 3: Deceleration is the decrease in speed of a moving object. Rationale 4: Blast injuries result from the temperature and velocity of air movement and the force of projectiles from the explosion. Global Rationale: A crushing injury occurs from a high force that leads to tissue destruction. The collapsing wall most likely caused crushing injuries. Shearing occurs when structures slip across each other. Deceleration is the decrease in speed of a moving object. Blast injuries result from the temperature and velocity of air movement and the force of projectiles from the explosion.

The nurse is providing medications to increase a patient's systemic vascular resistance. At which point will the nurse know that the patient has adequate tissue perfusion? 1. Mean arterial pressure reaches 60. 2. Mean arterial pressure reaches 90. 3. Blood pressure reaches 120/80 mmHg. 4. Urine output is 10 mL per hour.

Correct Answer: 1 Rationale 1: A mean arterial pressure of 60 mmHg is required to maintain adequate perfusion to the brain, heart, and kidneys. Rationale 2: A mean arterial pressure of 90 mmHg is considered within normal limits. Rationale 3: A blood pressure of 120/80 mmHg is considered normal. Rationale 4: A urine output of 10 mL per hour would not indicate adequate renal perfusion.

A patient is admitted to the hospital with injuries from a motor vehicle crash. During the nurse's initial assessment, the patient develops hypotension and severe jugular distension with a tracheal deviation. What should the nurse suspect is occurring in this patient? 1. tension pneumothorax 2. hemorrhage 3. compensatory shock 4. hypovolemic shock

Correct Answer: 1 Rationale 1: A tension pneumothorax is life-threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung. Rationale 2: The patient would not have jugular vein distention with a hemorrhage. Rationale 3: The patient would not have jugular vein distention with compensatory shock. Rationale 4: The patient would not have jugular vein distention with hypovolemic shock.

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)

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

A patient is admitted with a diagnosis of blunt trauma to the abdomen after a motor vehicle crash. What should the nurse assess first when the patient arrives in the emergency department? 1. airway for patency 2. abdomen for any abnormalities 3. cervical spine for tenderness 4. signs of neurological deficits

Correct Answer: 1 Rationale 1: Assessment of the airway is the highest priority in the trauma patient. Assessment includes determining airway patency. If the patient is unresponsive, manual opening of the airway using a jaw thrust or chin lift maneuver is necessary. Once the airway is opened, the practitioner must identify any potential obstruction from the tongue, loose teeth, foreign bodies, bleeding, secretions, vomitus, or edema. If the patient is responsive and can vocalize, that is a good indication that the airway is clear. Rationale 2: Another assessment must take place initially. Rationale 3: Another assessment must take place initially. Rationale 4: The nurse is always concerned about the neurological assessment of a patient, but this patient has a blunt trauma injury from a motor vehicle crash; therefore, this would not be the initial assessment.

A patient was admitted with a head injury caused by rapid acceleration and deceleration. How should the nurse expect this patient's injuries to be classified? 1. blunt 2. shearing 3. blast 4. minor

Correct Answer: 1 Rationale 1: Blunt trauma occurs when there is no communication between the damaged tissues and the outside environment. It is caused by various forces including deceleration, acceleration, shearing, compression, and crushing. Rationale 2: Shearing occurs when structures slip across each other. Rationale 3: Blast injuries result from the temperature and velocity of air movement and the force of projectiles from the explosion. Rationale 4: Minor trauma causes injury to a single part or system of the body and is usually treated in a physician's office or in the hospital emergency department.

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

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

The nurse is planning care for a patient diagnosed with shock. Which intervention should the nurse include to address this patient's problem of anxiety? 1. reducing stimuli and medicating for pain 2. assessing blood pressure and heart rate 3. monitoring central venous pressure 4. assessing bowel sounds

Correct Answer: 1 Rationale 1: Interventions appropriate for the problem of anxiety include reducing stimuli, which is calming and facilitates rest, and medicating for pain because pain precipitates or aggravates anxiety. Rationale 2: Assessing blood pressure and heart rate would be appropriate for a problem with cardiac output. Rationale 3: Monitoring central venous pressure would be appropriate for a problem with tissue perfusion. Rationale 4: Assessing bowel sounds would be appropriate for a problem with cardiac output.

A patient admitted with multiple injuries is prescribed an intravenous colloid solution. Which solution would be appropriate for the nurse to infuse? 1. 25% albumin 2. 0.9% normal saline 3. dextrose 5% and 0.45 % normal saline 4. dextrose 5% and water

Correct Answer: 1 Rationale 1: Colloid solutions contain substances that should not diffuse through capillary walls. Colloids tend to remain in the vascular system and increase the osmotic pressure of the serum, causing fluid to move into the vascular compartment from the interstitial space. As a result, plasma volume expands. Colloid solutions used to treat shock include 5% albumin, 25% albumin, hetastarch, plasma protein fraction, and dextran. Rationale 2: Crystalloid solutions contain dextrose or electrolytes such as normal saline dissolved in water; they are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and interstitial space. Rationale 3: Crystalloid solutions contain dextrose or electrolytes such as normal saline dissolved in water; they are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and interstitial space. Rationale 4: Crystalloid solutions contain dextrose or electrolytes such as normal saline dissolved in water; they are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and interstitial space.

An older patient is diagnosed with E. coli in the bloodstream. If not treated, the nurse realizes this patient is at risk for developing which types of shock? 1. distributive 2. obstructive 3. hypovolemic 4. anaphylactic

Correct Answer: 1 Rationale 1: Distributive shock includes several types of shock that result from widespread vasodilatation and decreased peripheral resistance. As the blood volume does not change, relative hypovolemia results. One example of distributive shock is septic shock. Septic shock is one part of a progressive syndrome called systemic inflammatory response syndrome and is most often the result of gram-negative bacterial infections such as E. coli. Rationale 2: Obstructive shock is caused by an obstruction in the heart or great vessels that either impedes venous return or prevents effective cardiac pumping action. Rationale 3: Hypovolemic shock occurs with a decrease in circulating blood volume. Rationale 4: Anaphylactic shock occurs as the result of a widespread humorally mediated hypersensitivity reaction.

A patient diagnosed with shock is prescribed dobutamine (Dobutrex). Which finding indicates this medication has been effective? 1. increased heart rate 2. reduced heart rate 3. decreased respiratory rate 4. decreased blood pressure

Correct Answer: 1 Rationale 1: Dobutamine (Dobutrex) is a medication that mimics the fight-or-flight response of the sympathetic nervous system. The physiologic effect is improved perfusion and oxygenation of the heart, with increased stroke volume and heart rate, and increased cardiac output. Increased cardiac output, in turn, increases tissue perfusion and oxygenation. Rationale 2: This medication will not reduce the heart rate. Rationale 3: This medication will not reduce the respiratory rate. Rationale 4: This medication will not reduce the blood pressure.

A patient is brought to the emergency department with gunshot wounds to the abdomen and lower extremities. To protect the chain of evidence for these injuries, what should the nurse do? 1. Remove the patient's clothing and place in a breathable bag. 2. Cover the patient's hands with plastic bags. 3. Cut off the patient's clothing and bathe the skin and wounds as soon as possible. 4. Place clothing and other patient items on a bedside table and have a nursing assistant remove them when possible.

Correct Answer: 1 Rationale 1: Each item of clothing removed from the patient must be placed in a breathable container, such as a paper bag, and documented appropriately. Rationale 2: The patient's hands should be covered with paper bags only if the patient died. Rationale 3: The clothing should not be cut off in order to bathe the patient's skin and wounds. Rationale 4: The patient's clothing and personal items should not be left on a bedside table for someone else to remove. This would not protect the chain of evidence.

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.

Correct Answer: 1 Rationale 1: Hyperventilating the patient lowers the ICP by lowering the PaCO that is causing vasoconstriction 2 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.

The nurse, caring for a patient who sustained a traumatic injury several days ago, notes that the patient is hypotensive, oliguric, and has cool, pale skin and acidosis. The nurse understands that these are manifestations of which type of shock? 1. hypovolemic 2. cardiogenic 3. septic 4. anaphylactic

Correct Answer: 1 Rationale 1: Hypovolemic shock is caused by a decrease in intravascular volume. In hypovolemic shock, the venous blood returning to the heart decreases, and ventricular fills drops. As a result, stroke volume, cardiac output, and blood pressure decrease. Hypovolemic shock affects all body systems. Rationale 2: Cardiogenic shock occurs when the heart's pumping ability is compromised to the point that it cannot maintain cardiac output and adequate tissue perfusion. Rationale 3: Patients at risk for developing infections leading to septic shock include those who are hospitalized, have debilitating chronic illnesses, or have poor nutritional status. Septic shock does not usually present in a patient with a traumatic injury. Rationale 4: Anaphylactic shock is the result of a widespread hypersensitivity reaction from medications, blood administration, latex, foods, snake venom, and insect stings.

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

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.

The nurse is preparing to administer intravenous nitroglycerin to a patient diagnosed with cardiogenic shock. What should the nurse do when administering this medication? 1. Use an infusion pump. 2. Administer with PVC tubing. 3. Use within 8 hours of reconstitution. 4. Allow the patient to get out of bed only with assistance.

Correct Answer: 1 Rationale 1: Intravenous nitroglycerin must be mixed in glass bottles and infused through special, non-PVC tubing, because up to 40%-80% of nitroglycerin can be absorbed by PVC bags or tubing. Rationale 2: Intravenous nitroglycerin should not be administered with PVC tubing, because up to 40%-80% of nitroglycerin can be absorbed by PVC bags or tubing. Rationale 3: This medication must be used within 4 hours of reconstitution. Rationale 4: The patient receiving intravenous nitroglycerin should be on bed rest, not assisted out of bed.

The nurse suspects that a patient diagnosed with a myocardial infarction is developing cardiogenic shock. What manifestation did the nurse assess to come to this conclusion? 1. jugular vein distention 2. warm extremities 3. laryngospasm 4. urticaria

Correct Answer: 1 Rationale 1: Jugular vein distention is seen in cardiogenic shock. Rationale 2: Warm extremities are seen in early septic shock and anaphylactic shock. Rationale 3: Laryngospasm is seen in anaphylactic shock. Rationale 4: Urticaria is seen in anaphylactic shock.

A patient is admitted with possible head and spinal cord injuries sustained after falling from a ladder. Which diagnostic test should the nurse expect to be prescribed that will identify the type and extent of this patient's injuries? 1. magnetic resonance imaging 2. cervical spine x-rays 3. spinal cord x-rays 4. cerebral angiogram

Correct Answer: 1 Rationale 1: Magnetic resonance imaging scans reveal injuries to the brain and spinal cord. Rationale 2: Cervical spine x-rays can detect fractures of the vertebrae but not injuries to the brain. Rationale 3: Spinal cord x-rays can detect fractures of the vertebrae but not injuries to the brain. Rationale 4: A cerebral angiogram can detect injuries to the brain but not to the spinal cord.

The spouse of a patient admitted with a gunshot wound asks the nurse when her husband will be discharged so that they can resume their life together. How should the nurse respond? 1. "Right now there is no way of knowing how soon your husband can return to his previous life." 2. "I would say in a few weeks." 3. "Probably never." 4. "As soon as the wound heals, your husband can return to work."

Correct Answer: 1 Rationale 1: Nurses provide a vital link in both the physical and psychosocial care to the injured patient and family. In caring for the patient who has experienced trauma, nurses must consider not only the initial physical injury, but also its long-term consequences, including rehabilitation. Trauma may alter the patient's previous way of life, potentially affecting independence, mobility, cognitive thinking, and appearance. The nurse should respond that there is no way of knowing how soon the patient can return to his previous life. Rationale 2: The nurse should not put a time limit of a few weeks on the patient's recovery from trauma. Rationale 3: The nurse should not tell the spouse that the patient will probably never return to his previous life. Rationale 4: The nurse has no way of knowing the extent of the damage caused by the gunshot wound and cannot predict when the patient can return to work.

A patient is diagnosed with a pneumothorax. The nurse realizes that unless this is treated, the patient is at risk for developing which type of shock? 1. obstructive 2. hypovolemic 3. cardiogenic 4. neurogenic

Correct Answer: 1 Rationale 1: Obstructive shock is caused by an obstruction in the heart or great vessels that either impedes venous return or prevents effective cardiac pumping action. One cause of obstructive shock is impaired diastolic filling, as seen in a pneumothorax. Rationale 2: Hypovolemic shock is seen in patients with a low circulating blood volume. Rationale 3: Cardiogenic shock can occur in patients who have experienced a myocardial infarction. Rationale 4: Neurogenic shock can occur in patients with spinal cord injuries.

The spouse of a patient admitted with severe head injury tells the nurse that she believes her husband is going to recover because he is continuing to make movements without stimulation. What should the nurse explain to the spouse? 1. "With head injuries, the patient can continue to make movements, but these are reflexes that do not reflect brain function." 2. "Your husband will likely recover in time." 3. "As long as he has oxygen to the brain, he will recover." 4. "His movements indicate that his brain is dead."

Correct Answer: 1 Rationale 1: One criterion of brain death is the lack of spontaneous movement; however, some spinal cord reflexes may be present. Rationale 2: The nurse should not tell the spouse that the patient will recover in time. Rationale 3: The nurse should not tell the spouse that the patient will recover as long as he has oxygen to the brain. Rationale 4: The patient has a brain injury; his movements are likely spinal cord reflexes rather than spontaneous movements. Additional testing must be done before brain death is diagnosed.

A patient is brought to the emergency department with a penetrating wound to the neck. The patient is dyspneic and cyanotic and has evidence of subcutaneous emphysema. What does the nurse expect the physician to do initially? 1. intubate the patient because of the severe wound 2. notify the next of kin regarding the patient's condition 3. order x-rays of the lumbar area to assess for fractures 4. administer a beta blocker to alleviate the sympathetic response

Correct Answer: 1 Rationale 1: Penetrating trauma to the neck is associated with a high degree of morbidity and mortality. Airway involvement includes dyspnea, cyanosis, subcutaneous emphysema, hoarseness, or air bubbling from the wound. The key is early identification of the need for intubation before the patient has no airway at all. Rationale 2: Another action is more critical initially. Rationale 3: Another action is more critical initially. Rationale 4: Another action is more critical initially.

The nurse identifies the problem of impaired physical mobility in a patient hospitalized with traumatic injuries. Which intervention should the nurse identify as appropriate for this patient? 1. Provide active range-of-motion exercises to affected extremities every 8 hours. 2. Turn and reposition every hour. 3. Remove anti-embolic stockings for 3 hours every shift. 4. Administer tetanus toxoid.

Correct Answer: 1 Rationale 1: The patient with impaired physical mobility should have active range-of-motion exercises to the affected extremities once every 8 hours. Rationale 2: The patient should be turned and repositioned every 2 hours. Rationale 3: Anti-embolic stockings should be removed for 1 hour every shift. Rationale 4: Administering the tetanus toxoid would be appropriate for reducing the risk for infection.

A female who was a victim of rape 6 months ago comes to an outpatient clinic for the treatment of posttraumatic stress disorder. Which data collected during the patient's assessment indicates a manifestation associated with this disorder? 1. The patient described severe nightmares related to the event. 2. The patient denied anger or shock. 3. The patient denied the need for drug or alcohol counseling. 4. The patient stated that her family is very supportive.

Correct Answer: 1 Rationale 1: Posttraumatic stress disorder is an intense, sustained emotional response to a disastrous event. It is characterized by emotions that range from anger to fear, and by flashbacks or psychic numbing. In the initial stage, the patient can be calm or might express feelings of anger, disbelief, terror, and shock. In the long-term phase, which begins anywhere from a few days to several months after the event, the patient often experiences flashbacks and nightmares of the traumatic event. The patient also might call on ineffective coping mechanisms, such as alcohol or drugs, and withdraw from relationships. Rationale 2: Feelings of anger and shock are associated with posttraumatic stress disorder. Rationale 3: Patients who suffer from posttraumatic stress disorder are more prone to using alcohol or drugs. Rationale 4: These patients usually withdraw from relationships.

A patient diagnosed with hypovolemic shock is prescribed intravenous fluids while awaiting blood transfusions. Which solution does the nurse recognize would be best for this patient? 1. Ringer's lactate 2. Dextrose 5% and water 3. Dextrose 5% and 0.45% normal saline 4. Dextrose 5% and 0.9% normal saline

Correct Answer: 1 Rationale 1: Ringer's lactate and 0.9% saline are the fluids of choice in treating hypovolemic shock, especially in the emergency phase of care while blood is being typed and crossmatched. Large amounts of these solutions may be infused rapidly, increasing blood volume and tissue perfusion. Rationale 2: Hypotonic crystalloid solutions, such as dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. But approximately 25% of the fluid stays within the intravascular space, increasing the risk of peripheral edema. Rationale 3: Hypotonic crystalloid solutions, such as dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. But approximately 25% of the fluid stays within the intravascular space, increasing the risk of peripheral edema. Rationale 4: Hypotonic crystalloid solutions, such as dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. But approximately 25% of the fluid stays within the intravascular space, increasing the risk of peripheral edema.

The nurse determines that a patient is experiencing ongoing progression of a shock state. What finding led the nurse to come to this conclusion? 1. decrease in serum glucose level 2. drop in blood urea nitrogen level 3. increased eosinophil level 4. low serum cardiac enzyme level

Correct Answer: 1 Rationale 1: Serum electrolyte levels are assessed to monitor the severity and progression of shock. As shock progresses, serum glucose levels decrease. Rationale 2: A drop in blood urea nitrogen level means the kidneys are receiving adequate blood flow. Rationale 3: An increase in eosinophils indicates an allergic response. Rationale 4: Low serum cardiac enzymes indicate there is no myocardial damage.

A construction worker was admitted after falling from the roof of a building. The nurse should plan care for this patient's injuries based on which energy source? 1. gravitational 2. mechanical 3. physical 4. electrical

Correct Answer: 1 Rationale 1: The energy source for a fall is gravitational. Rationale 2: The energy source for motor vehicle accidents is mechanical. Rationale 3: The energy source for physical assaults, explosions, and drowning is physical. Rationale 4: The energy source for lightning is electrical.

A pediatric patient is admitted after ingesting a household cleaning solution. The nurse should plan care for this patient's injuries based on which energy source? 1. chemical 2. physical 3. thermal 4. mechanical

Correct Answer: 1 Rationale 1: The energy source for drugs, poisons, and industrial chemicals is chemical. Rationale 2: The energy source for physical assault, drowning, or explosions is physical. Rationale 3: The energy source for heating appliances, fire, or freezing temperatures is thermal. Rationale 4: The energy source for motor vehicle accidents is mechanical.

A patient is admitted with a thermal injury. Which mechanism of injury should the nurse consider as the most likely cause of this patient's injuries? 1. fire 2. lightning 3. ultraviolet radiation 4. gunshot

Correct Answer: 1 Rationale 1: The energy source for the patient's injury is thermal. Mechanisms of injury for thermal injuries include fire, heating appliances, and freezing temperatures. Rationale 2: The energy source for lightning is electrical. Rationale 3: The energy source for ultraviolet radiation is physical. Rationale 4: The energy source for a gunshot is mechanical.

A patient is brought to the emergency department with physical injuries sustained in a gang fight. The patient's blood pressure is 80/50 mmHg, with a pulse of 120 and thready. Which diagnostic test should the nurse expect to be performed to provide the fastest information? 1. sonogram 2. complete blood count 3. urinalysis 4. serum electrolyte levels

Correct Answer: 1 Rationale 1: The focused assessment by sonography in trauma, or FAST, identifies blood in body cavities where it is not supposed to be. The primary focus is on the peritoneum. Because the patient was in a fight and has a low blood pressure and thready pulse, this diagnostic test would provide the fastest information. Rationale 2: A complete blood count would not provide the fastest information for this patient. Rationale 3: A urinalysis would not provide the fastest information for this patient. Rationale 4: Serum electrolyte levels would not provide the fastest information for this patient.

A patient recovering from a motor vehicle accident tells the nurse that the other car "barely" hit him and asks why he has so many injuries. How should the nurse respond? 1. "The car that hit you transferred a large amount of energy to your body, causing these injuries." 2. "You have other health problems that make the injuries worse." 3. "The driver of the other car intended to hit you." 4. "Because you are older, your injuries will be worse."

Correct Answer: 1 Rationale 1: The nurse should explain the transfer of energy to the patient's body that caused the injuries. Rationale 2: Referring to other health problems identifies characteristics of the host but does not explain the number or types of injuries. Rationale 3: This response addresses the intention of the trauma but does not explain the number or types of injuries. Rationale 4: Referring to the patient's age identifies characteristics of the host but does not explain the number or types of injuries.

A patient is admitted with severe facial injuries from a motor vehicle crash. For what should the nurse first assess this patient? 1. signs of stridor, cough, or respiratory distress 2. blood pressure 3. need for suctioning 4. loose teeth or obvious problems with the mouth

Correct Answer: 1 Rationale 1: The patient with multiple injuries is at great risk for developing airway obstruction and apnea. All of the choices are important; however, the most important assessment is for a patent and maintainable airway. The nurse should assess for manifestations of airway obstruction including stridor, tachypnea, bradypnea, cough, cyanosis, dyspnea, decreased or absent breath sounds, changes in oxygen levels, and changes in level of consciousness. Rationale 2: The blood pressure can be assessed after the patient is assessed for respiratory distress. Rationale 3: The need for suctioning can be determined after it has been determined that the patient has an adequate airway. Rationale 4: Assessment of the mouth can occur after determining that the patient has an adequate airway.

The nurse wants to calculate a patient's mean arterial pressure. Which vital sign measurement should the nurse use to make this calculation? 1. blood pressure 2. temperature 3. respirations 4. heart rate

Correct Answer: 1 Rationale 1: The patient's blood pressure is needed to make this calculation. The mean arterial pressure can be calculated by multiplying the diastolic blood pressure by 2, adding the systolic pressure, and dividing this total by 3. Rationale 2: Temperature is not used to calculate mean arterial pressure. Rationale 3: Respiratory rate is not used to calculate mean arterial pressure. Rationale 4: Heart rate is not used to calculate mean arterial pressure.

A patient with multiple gunshot wounds to the abdomen has received 8 units of blood. The blood bank notifies the nurse that they have run out of blood for the patient. The nurse knows the patient can receive any type of blood if the patient has which blood type? 1. AB 2. A 3. B 4. O

Correct Answer: 1 Rationale 1: The person with type AB blood has no antibodies, can receive any type of blood in an emergency, and is referred to as a universal recipient. Rationale 2: The person with blood type A has B antibodies. Rationale 3: The person with type B has A antibodies. Rationale 4: A person with the O blood type has both A and B antibodies and is considered a universal donor in an emergency situation.

The nurse suspects that a patient who was in a motor vehicle crash does not have a cervical spine injury. What did the nurse assess to come to this conclusion? 1. alert without midline cervical tenderness 2. lacking motor response in lower extremities 3. lacking deep tendon reflexes 4. lethargic and confused

Correct Answer: 1 Rationale 1: There is a decreased probability of a cervical spine injury if the following criteria are met: absence of midline cervical spine tenderness; normal alertness; absence of intoxication; absence of a painful distracting injury; and no focal neurological deficits. Rationale 2: A lack of motor response would be an indication of a cervical spine injury. Rationale 3: A lack of deep tendon reflexes would be an indication of a cervical spine injury. Rationale 4: Lethargy and confusion would be indications of a cervical spine injury.

A patient is brought to the emergency department with injuries sustained in a motor vehicle crash. What should the nurse consider as the cause of this patient's injuries? 1. trauma 2. not wearing a seat restraint 3. a drunk driver 4. not paying attention while driving

Correct Answer: 1 Rationale 1: Trauma is defined as injury to human tissues and organs resulting from the transfer of energy from the environment. Trauma encompasses a variety of injuries, including those from motor vehicle crashes. Rationale 2: There is insufficient information to determine whether the patient was wearing a seat restraint. Rationale 3: There is insufficient information to determine whether the accident was caused by a drunk driver. Rationale 4: There is insufficient information to determine whether the patient was paying attention while driving.

A patient comes into the emergency department with leg pain after falling on ice. For which classification of injuries should the nurse expect to plan care for this patient? 1. Class 3 minor 2. Class 1 minor 3. Class 1 penetrating 4. Class 3 penetrating

Correct Answer: 1 Rationale 1: Trauma patients are classified as Class 1, 2, or 3 based on factors including mechanism of injury, vehicle speed, height of falls, and location of penetrating injuries. Class 3 trauma is the least severe. An example would be a same-level fall without loss of consciousness or significant injury. Rationale 2: Class 1 trauma involves life-threatening injuries likely to require medical specialists or immediate surgical intervention. Minor trauma causes injury to a single part or system of the body and is usually treated in a physician's office or in the hospital emergency department. A single bone fracture, small second-degree burns, or a laceration requiring sutures are examples of minor trauma. Rationale 3: Penetrating trauma occurs when a foreign object enters the body, causing damage to body structures. Rationale 4: Penetrating trauma occurs when a foreign object enters the body, causing damage to body structures.

A patient with multiple traumatic injuries has experienced severe blood loss and is prescribed to receive blood immediately. The nurse realizes that because there is not enough time for type and crossmatch, the patient will most likely receive which type of blood? 1. O 2. A 3. B 4. AB

Correct Answer: 1 Rationale 1: Type O blood is the universal donor. ABO antibodies develop in the serum of people whose RBCs lack the corresponding antigen; these antibodies are called anti-A and anti-B. Rationale 2: The person with blood type A has B antibodies. Rationale 3: The person with blood type B has A antibodies. Rationale 4: The person with AB has no antibodies (called a universal recipient).

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.

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.

An adult patient who has died from traumatic injuries is an organ donor. What should the nurse do when caring for this patient? 1. Maintain systolic blood pressure of 90 mmHg. 2. Keep oxygen saturation level at 75%. 3. Administer intravenous fluids to maintain a urine output of 25 mL per hour. 4. Perform external cardiac compressions to achieve a heart rate of 60 beats per minute.

Correct Answer: 1 Rationale 1: When caring for an adult patient who is an organ donor, the nurse should maintain systolic blood pressure of 90 mmHg to keep the patient's organs perfused until removal. Rationale 2: The oxygen saturation level needs to be kept at 90% or greater. Rationale 3: Medications and fluids are provided to keep urine output at more than 30 mL per hour. Rationale 4: External cardiac compressions should not be performed.

A patient has an estimated blood loss of 2 liters and a mean arterial pressure ranging between 30 and 40 mmHg. If this patient's hemodynamic status is not corrected, what should the nurse realize can occur? 1. failure of sodium-potassium pump 2. cells shrinking 3. full and bounding peripheral pulses 4. metabolic alkalosis

Correct Answer: 1 Rationale 1: With a blood loss of 2 liters and a mean arterial pressure below 60 mmHg, the body cells switch from aerobic to anaerobic metabolism. The lactic acid formed as a by-product of anaerobic metabolism contributes to an acidotic state at the cellular level. Adenosine triphosphate, the source of cellular energy, is produced inefficiently. Lacking energy, the sodium-potassium pump fails. Potassium moves out of the cells while sodium and water move inward. Rationale 2: As this process continues, the cells swell, not shrink. Rationale 3: Peripheral pulses may not be palpable. Rationale 4: The body develops acidosis, not alkalosis.

A patient with traumatic injuries has lost approximately 300 mL of blood. What should the nurse expect to assess in this patient? 1. slight increase in heart rate 2. nonpalpable peripheral pulses 3. narrowing pulse pressure 4. increase in blood glucose level

Correct Answer: 1 Rationale 1: With a slight decrease in circulating blood volume, usually less than 500 mL, the symptoms of shock are almost imperceptible. The pulse rate may be slightly elevated. If the injury is minor or of short duration, arterial pressure is usually maintained and no further symptoms occur. Rationale 2: Nonpalpable peripheral pulses are a sign of progressive shock. The patient is not in progressive shock. Rationale 3: Narrowing pulse pressure is a sign of progressive shock. The patient is not in progressive shock. Rationale 4: An increase in blood glucose level is a sign of progressive shock. The patient is not in progressive shock.

A victim of a multivehicle automobile crash is brought into the emergency department. The patient has slurred speech and is lethargic. The nurse anticipates that which diagnostic tests would be indicated for this patient? Standard Text: Select all that apply. 1. blood alcohol level 2. urine drug screen 3. skull x-rays 4. chest x-ray 5. urinalysis

Correct Answer: 1, 2 Rationale 1: Alcohol alters a person's level of consciousness, so a blood alcohol level would likely be ordered for a patient with slurred speech and lethargy. Rationale 2: Some drugs can cause lethargy and slurred speech. A urine drug screen would likely be ordered for this patient. Rationale 3: This diagnostic test may or may not be indicated for the patient. Rationale 4: A chest x-ray would likely be ordered, but not because of the slurred speech or lethargy. Rationale 5: Urinalysis will most likely be done however not because of slurred speech or lethargy.

An older patient is admitted after falling on the steps at home. Which components of trauma should the nurse consider when planning care for the patient? Standard Text: Select all that apply. 1. host 2. environment 3. intention 4. source 5. transmission

Correct Answer: 1, 2, 3 Rationale 1: The host is the person or group at risk of injury. Multiple factors influence the host's potential for injury: age, sex, race, economic status, preexisting illnesses, and use of substances such as street drugs and alcohol. Rationale 2: The environment in which the trauma occurred needs to be taken into consideration. Rationale 3: The event was either intentional or unintentional. As the patient fell on the steps at home, the event was most likely unintentional. Rationale 4: Source is not a component of a traumatic event. Rationale 5: Transmission is not a component of a traumatic event.

A patient with thoracic injuries sustained in a multivehicle crash is demonstrating an alteration in perfusion. What should the nurse do to help this patient? Standard Text: Select all that apply. 1. Auscultate lung sounds. 2. Measure blood pressure. 3. Measure central venous pressure. 4. Reduce rate of intravenous fluids. 5. Assess for jugular vein distention.

Correct Answer: 1, 2, 3, 5 Rationale 1: For an alteration in perfusion, the nurse should auscultate lung sounds. Rationale 2: For an alteration in perfusion, the nurse should measure blood pressure. Rationale 3: For an alteration in perfusion, the nurse should measure current central venous pressure. Rationale 4: Reducing intravenous fluids could exacerbate the problem. Rationale 5: For an alteration in perfusion, the nurse should assess for jugular vein distention.

The nurse is concerned that a patient with traumatic chest injures is developing respiratory distress. What assessment findings led the nurse to come to this conclusion? Standard Text: Select all that apply. 1. combative behavior 2. absent breath sounds in left lower lobe 3. pedal and popliteal pulses weak and irregular 4. temperature raised 2 degrees over the last 4 hours 5. oxygen saturation 86% on 40% oxygen face mask

Correct Answer: 1, 2, 5 Rationale 1: An early sign of an ineffective airway is a change in the patient's behavior. If the patient becomes combative, the nurse immediately assesses the effectiveness of the airway. Rationale 2: Absent breath sounds can indicate airway obstruction. Rationale 3: Changes in lower extremity pulses indicate an alteration in perfusion. Rationale 4: Changes in body temperature indicate an infectious process. Rationale 5: Oxygen saturation is a measurement of airway effectiveness. Oxygen flow should be adjusted to keep saturation level between 94% and 100%.

The nurse assesses a patient with a penetrating abdominal wound as a Class IV hemorrhage because of which findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: 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

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.

A patient receiving a unit of packed red blood cells for hypovolemic shock is demonstrating signs of a transfusion reaction. In which order should the nurse provide care to this patient? Standard Text: Click and drag the options below to move them up or down. 1: Stop the transfusion and notify the physician 2: Compare the blood slip with the unit of blood 3: Assess vital signs and associated manifestations 4: Save the blood bag and tubing for laboratory analysis 5: Collect urine and venous blood samples according to policy

Correct Answer: 1, 3, 2, 4, 5 Rationale 1: The first step is to immediately stop the infusion and notify the physician. Rationale 2: The third step is to compare the blood slip with the unit of blood to ensure that an identification error was not made. Rationale 3: The second step is to assess vital signs and assess for other manifestations. Rationale 4: The fourth step is to save the blood bag and any remaining blood for return to the laboratory for testing to determine the cause of the reaction. Rationale 5: The fifth step is to follow organizational policy for collecting urine and venous blood samples.

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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: 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

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.

A patient with a traumatic brain injury is being evaluated for brain death. Which findings should the nurse expect in this patient? 1. An absence of the gag or corneal reflex 2. An absence of the oculovestibular reflex 3. Apnea with PaCO2 of 66 mmHg 4. Toxic metabolic disorder

Correct Answer: 1,2,3 Rationale 1: An absence of the gag or corneal reflex is a clinical sign that is consistent with brain death. Rationale 2: An absence of the oculovestibular reflex is a clinical sign that is consistent with brain death. Rationale 3: Apnea with PaCO2 of 66 mmHg is a clinical sign that is consistent with brain death. Rationale 4: Toxic metabolic disorders are not consistent with brain death.

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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Hoarse speech 2. Pain when swallowing 3. Coughing blood 4. Epistaxis 5. Periorbital edema

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.

During the assessment of a patient with a suspected cardiac tamponade, the nurse should monitor for the development of: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Pulsus paradoxus 2. Muffled heart sounds 3. Hypotension 4. Flat jugular veins

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.

The nurse is caring for a patient with a traumatic injury to the abdomen who is prescribed conservative, nonoperative management. Which ongoing assessments should the nurse include in the plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: 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

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.

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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: 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

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.

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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: 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

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

Which will the nurse assess when evaluating breathing in a patient suspected of having a thoracic trauma? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: 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

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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: 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.

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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Pleural effusion 2. Subcutaneous emphysema 3. Tracheal shift 4. Vertebral column injury 5. Bladder rupture

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.

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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: 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.

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 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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: 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

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.

What can the nurse do to convey comfort to a trauma patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: 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.

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.

Which goals are appropriate for a patient with a traumatic injury and an ineffective breathing pattern? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: 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

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.

Immediate interventions for a patient with a sucking chest wound include: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: 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.

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.

When performing a quick assessment to identify life-threatening problems in a trauma patient, the nurse would include which assessments under the D-Disability section? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Ability to respond to painful stimuli 2. Vital signs 3. Ability to respond to verbal command 4. Level of consciousness or unconsciousness 5. Oxygen saturation levels

Correct Answer: 1,3,4 Rationale 1: This is assessed under the disability part of the primary assessment. Rationale 2: Vital signs are classified under F-Full set of vital signs. Rationale 3: This is assessed under the disability part of the primary assessment. Rationale 4: This is assessed under the disability part of the primary assessment. Rationale 5: Oxygen levels are covered under C-Circulation of the primary assessment steps.

The nurse would include which activities when planning care to increase comfort for the intubated patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: 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

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.

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

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.

A patient arrives in the emergency department with a flail chest after a motor vehicle accident (MVA) in which the patient's chest hit the steering wheel. The nurse realizes this injury is due to: 1.Blunt trauma from internal forces caused by acceleration 2.Blunt trauma from external forces caused by deceleration 3.Penetrating trauma from external forces caused by deceleration 4.Penetrating trauma from internal forces caused by acceleration

Correct Answer: 2 Rationale 1: Internal forces refer to stress or strain created within the body, not from outside forces. Acceleration forces are when the increasing speed hits someone who is stationary, such as a car hitting a person crossing the street. Rationale 2: Blunt trauma leaves the skin intact and damage to underlying tissue, such as broken ribs. External forces are created by the mass of the object and velocity of movement outside the body and the weight of the person being pushed forward after the car hit something. Deceleration is the force that stops or decreases the velocity of the moving victim, such as the chest hitting the steering wheel. Rationale 3: Penetrating wounds have an open wound and flail chests are intact at the skin level. Rationale 4: Penetrating wounds have an open wound and flail chests are intact at the skin level. Internal forces refer to stress or strain created within the body, not from outside forces.

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 manage ment, 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

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

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.

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.

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

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 asthm

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.

A trauma patient is being assessed with the Champion Revised Scoring System. What assessment data should the nurse use with this scoring system? Standard Text: Select all that apply. 1. diastolic blood pressure 2. heart rate 3. Glasgow coma scale 4. systolic blood pressure 5. respiratory rate

Correct Answer: 3, 4, 5 Rationale 1: Diastolic blood pressure is not included in the Champion Revised Scoring System. Rationale 2: Heart rate is not included in the Champion Revised Scoring System. Rationale 3: The Champion Revised Scoring System analyzes three elements, including the Glasgow Coma Scale. The patient receives a total score; the highest score is 12. Rationale 4: The Champion Revised Scoring System analyzes three elements, including the systolic blood pressure. The patient receives a total score; the highest score is 12. Rationale 5: The Champion Revised Scoring System analyzes three elements, including respiratory rate. The patient receives a total score; the highest score is 12.

Emergency personnel are preparing to complete an on-the-scene rapid assessment of a victim of a motor vehicle crash. In which order should the victim's assessment be completed? Place the assessments in order of importance. Standard Text: Click and drag the options below to move them up or down. 1. assessment for obvious injuries 2. Champion Revised Trauma Scoring System 3. airway and breathing assessment 4. circulation assessment 5. level of consciousness and pupillary function

Correct Answer: 3, 4, 5, 1, 2 Rationale 1: The fourth step is to assess for obvious injuries. Rationale 2: The last step is to use the Champion Revised Trauma Scoring System. Rationale 3: The first step is to assess the patient's airway and breathing. Rationale 4: The second step is to assess the patient's circulatory system.

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

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.

Which patient sustained an open traumatic injury? A patient with: 1. A closed hip fracture that was caused by a fall 2. A gun shot wound without penetration of the bullet due to the bullet-proof vest 3. Near-drowning after falling through a frozen lake 4. Burns over 30% of the body from a house fire

Correct Answer: 4 Rationale 1: This is an example of blunt trauma in which the skin is not broken, but underlying tissue is damaged. Rationale 2: This is an example of blunt trauma in which the skin is not broken, but underlying tissue is damaged. Rationale 3: This is an example of blunt trauma in which the skin is not broken, but underlying tissue is damaged. Rationale 4: Burns over 30% of the body from a house fire is an example of an open or penetrating wound in which the skin does not remain intact.