Chapter 33
.An unresponsive trauma patient has been admitted to the emergency department. Which statement regarding opening the airway is accurate? a. Airway assessment must incorporate cervical spine immobilization. b. Hyperextension of the neck is the only acceptable technique. c. Flexion of the neck protects the patient from further injury. d. Airway patency takes priority over cervical spine immobilization.
ANS: A Airway assessment must incorporate cervical spine immobilization. The patient's head should not be rotated, hyperflexed, or hyperextended to establish and maintain an airway. The cervical spine must be immobilized in all trauma patients until a cervical spinal cord injury has been definitively ruled out.
A patient who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distention, tracheal deviation to the left, and decreased breath sounds on the right side. The nurse suspects these findings are indicative of which disorder? a. Tension pneumothorax b. Cardiac tamponade c. Simple pneumothorax d. Ruptured diaphragm
ANS: A Clinical manifestations of a tension pneumothorax include dyspnea, tachycardia, hypotension, and sudden chest pain extending to the shoulders. Patients with cardiac tamponade will not have unilateral decreased breath sounds. Neither a simple pneumothorax nor a ruptured diaphragm will result in hypotension, jugular venous distention, or tracheal deviation unless it goes untreated
A patient has sustained an epidural hematoma after a 10-foot fall from a roof. The nurse understands that an epidural hematoma is a condition that has which characteristic? a. Usually arterial in nature b. Worse mortality rate than subdural hematomas c. Associated with a permanent loss of consciousness d. Signs and symptoms include bilateral pupil dilation
ANS: A Epidural hematoma (EDH) is a collection of blood between the inner table of the skull and the outermost layer of the dura. EDHs are most often associated with skull fractures and middle meningeal artery lacerations (two thirds of patients). 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.
A patient is admitted with acute abdominal trauma. The patient has a positive Focused Assessment with Sonography for Trauma (FAST scan) and is hemodynamically unstable. What procedure should the nurse anticipate next? a. Emergency surgery b. Diagnostic peritoneal lavage (DPL) c. Computed tomography scan d. Intraabdominal pressure monitoring
ANS: A Hemodynamically unstable patients with a positive Focused Assessment with Sonography for Trauma (FAST) scan generally undergo emergency surgery to achieve hemostasis. Diagnostic peritoneal lavage (DPL) is undertaken less frequently in many trauma centers. Computed tomography (CT) scanning is the mainstay of diagnostic evaluation in the hemodynamically stable patient with abdominal trauma; however, when the patient is hemodynamically unstable, the patient is taken to surgery. Intraabdominal pressure monitoring is done in the presence of intraabdominal hypertension.
A patient with a Le Fort III facial fracture has been admitted to the critical care unit. Which statements is true regarding this type of facial fracture? a. It is frequently associated with cerebrospinal fluid leaks. b. It is not as severe as Le Forte I and II injuries. c. The patient's airway is not usually compromised. d. It is associated with a low risk for hemorrhagic shock.
ANS: A Le Fort III fractures are associated with craniofacial disruption. Cerebrospinal fluid frequently leaks with Le Fort II and III fractures because there is frequently communication between the cranial base and the cribriform plate. Patients are at risk of airway occlusion from the tongue, hemorrhage, broken teeth, emesis, or bone fragments. Significant blood loss can occur with these injuries because of the extensive soft tissue and vascular damage that results
During assessment of a new trauma patient, the nurse observes perianal ecchymosis. The nurse suspects the patient has what problem? a. Pelvic fracture b. Bladder trauma c. Rectal laceration d. Spleen laceration
ANS: A Signs of pelvic fracture include swelling, tenderness, and/or bruising to the pubis, iliac bones, hips, or sacrum. Perianal ecchymosis (scrotum or vulva), indicating extravasation of urine or blood, may be present.
A patient was thrown 30 feet from an open-top Jeep and straddled a row of mailboxes before landing on the ground. The patient has an open pelvic fracture. What characteristics of this injury are important for the nurse to understand? a. Aggressive fluid and blood replacement will probably be needed. b. The patient will probably be able to walk as soon as the patient is stable. c. The patient 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.
A patient with multisystem trauma has been in the intensive care unit (ICU) for 6 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The patient's vital signs include blood pressure (BP), 92/66 mm Hg; heart rate (HR), 118 beats/min; temperature (T), 38.7° C; and central venous pressure (CVP), 5 mm Hg. What is the most likely cause of this hemodynamic picture? a. Septic shock b. Hemorrhagic shock c. Cardiogenic shock d. Neurogenic shock
ANS: A The patient with multiple injuries is at risk for overwhelming infections and sepsis. The source of sepsis in the trauma patient can be invasive therapeutic and diagnostic catheters or wound contamination with exogenous or endogenous bacteria. The source of the septic nidus must be promptly evaluated. Gram stain and cultures of blood, urine, sputum, invasive catheters, and wounds are obtained.
A patient developed a hemothorax after a blunt chest trauma. The practitioner inserted a chest tube on the left side, and 1800 mL of blood was evacuated from the chest. The nurse expects that the patient will be taken to surgery for what procedure? a. Thoracotomy b. Pericardiocentesis c. Splenectomy d. Pneumonectomy
ANS: A Thoracotomy may be necessary for patients who require persistent blood transfusions or who have significant bleeding (200 mL/h for 2 to 4 hours or more than 1500 mL on initial tube insertion) or when there are injuries to major cardiovascular structures.
A trauma patient's condition has deteriorated. The nurse notes changes in patient's condition, including trachea shift, absence of breath sounds on the left side, and hypotension. The nurse suspects that the patient has developed what complication? a. Cardiac tamponade b. Hemothorax c. Open pneumothorax d. Ruptured diaphragm
ANS: B Assessment findings for patients with a hemothorax include hypovolemic shock. Breath sounds may be diminished or absent over the affected lung. With hemothorax, the neck veins are collapsed, and the trachea is at midline. Massive hemothorax can be diagnosed on the basis of clinical manifestations of hypotension associated with the absence of breath sounds or dullness to percussion on one side of the chest.
A patient was admitted after a motor vehicle crash (MVC). The nurse knows that this type of injury is the greatest cause of what type of trauma? 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 motor vehicle crashes (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 (eg, 22-caliber gun, knife) usually damage only what is in the weapon's direct path.
A patient is admitted with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. Nursing care for the patient includes which intervention? a. Keep the room cool, dark, and quiet. b. Maintain mean arterial pressure (MAP) at 85 to 95 mm Hg. c. Elevate the head of the bed 45 degrees. d. Resuscitate low blood pressure by only using intravenous fluid.
ANS: B Management of acute cervical spinal cord injury (SCI) involves close hemodynamic monitoring. Current guidelines for the management of acute cervical SCI cite that hypotension (systolic blood pressure less than 90 mm Hg) should be avoided or corrected as soon as possible after acute SCI. It is also considered an option to maintain the mean arterial pressure (MAP) at 85 to 90 mm Hg for the first 5 to 7 days after acute SCI to improve spinal cord perfusion. 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.
A patient is admitted to the intensive care unit (ICU) for observation of his grade II splenic laceration. Which signs and symptoms suggest that the patient has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock? a. Blood pressure (BP), 110/70 mm Hg; HR, 120 beats/min; Hct, 42 mg/dL; UO, 40 mL/h; 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/h; pale, cool, clammy skin; confused c. BP, 100/60 mm Hg; HR, 100 beats/min; Hct, 35 mg/dL; UO, 30 mL/h; pale, cool, dry skin; alert and oriented d. BP, 110/60 mm Hg; HR, 118 beats/min; Hct, 38 mg/dL; UO, 60 mL/h; 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
A patient is admitted with a blunt cardiac injury (BCI) with no evidence of rupture. The nursing management plan should include which intervention? a. Administer nitroglycerine for chest pain as needed. b. Monitor the patient for new onset dysrhythmias. c. Monitor serial biomarkers for evidence of further damage. d. Do not administer antidysrhythmic medications, as they are ineffective.
ANS: B The patient should be monitored for new onset of dysrhythmias. The patient may complain of chest pain that is similar to anginal pain, but it is not typically relieved with nitroglycerin. Chest pain is usually caused by associated injuries. Use of biomarkers, such as troponin, offers very little diagnostic help for blunt cardiac injury (BCI). Medical management is aimed at preventing and treating complications. This approach includes hemodynamic monitoring in a critical care unit and possible administration of antidysrhythmic medications.
A patient has been admitted with a flail chest and pulmonary contusion. Which finding will cause a nurse to suspect that the patient's condition is deteriorating? a. Increased bruising on the chest wall b. Increased need for pain medication c. The development of respiratory alkalosis d. Increased work of breathing
ANS: D A contusion manifests initially as a hemorrhage followed by alveolar and interstitial edema. Patients with severe contusions may continue to show decompensation, such as respiratory acidosis and increased work of breathing, despite aggressive nursing management. Increased bruising and the need for pain medication are not signs of deterioration.
The nurse understands that certain trauma patients are at risk for developing fat embolism syndrome. Which group of patients is a high risk for this complication? a. Patients with liver trauma b. Patients with burns c. Patients with orthopedic trauma d. Patients with spleen trauma
ANS: C Fat embolism syndrome can occur as a complication of orthopedic trauma.
The nurse is working on an organization-wide falls prevention project. The nurse understands that the majority of falls accounting for traumatic injury occur in what population? a. Construction workers b. Adolescents c. Older adults d. Young adults
ANS: C Older persons experience most of the falls that result in injuries, and these falls are likely to occur from level surfaces or steps. Because many of the falls may be caused by an underlying medical condition (eg, syncope, myocardial infarction, dysrhythmias), management of an older patient who has fallen must include an evaluation of events and conditions immediately preceding the fall.
A patient is admitted with a severe diffuse axonal injury (DAI) secondary to a motor vehicle crash. The patient's plan of care would involve which nursing action? a. Perform neurologic assessments once a shift. b. Obtain a computed tomography (CT) scan every day. c. Monitor blood pressure and temperature every hour. d. Initiate warming measures to keep temperature greater than 37.5° C.
ANS: C Severe diffuse axonal injury (DAI) usually manifests as a prolonged, deep coma with periods of hypertension, hyperthermia, and excessive sweating. Treatment of DAI includes support of vital functions. The outcome after severe DAI is poor because of the extensive dysfunction of cerebral pathways. Neurologic assessment is performed every hours. DAI may not be visible on computed tomography (CT) scan. Warming measures are generally not needed, but cooling measure may be needed.
A patient has been admitted with a flail chest. What findings would the nurse expect to note supporting this diagnosis? a. Tracheal deviation toward the unaffected side b. Jugular venous distention c. Paradoxical respiratory movement d. Respiratory alkalosis
ANS: C Tracheal deviation and jugular venous distention are findings associated with tension pneumothorax. Respiratory acidosis is usually present because of the ineffective breathing pattern. In a flail chest, a free-floating segment of the chest wall moves independently from the rest of the thorax and results in paradoxical chest wall movement during the respiratory cycle. During inspiration, the intact portion of the chest wall expands while the injured part is sucked in. During expiration, the chest wall moves in, and the flail segment moves out.
A patient with multisystem trauma has been in the critical care unit for 2 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The nurse understands that immobility places the patient at risk for developing which complication? a. Pneumonia b. Infection c. Venous thromboembolism d. Fat embolism syndrome
ANS: C 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.
A patient is admitted with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. The nurse suspects the patient may have which type of injury? a. Posterior cord syndrome b. Brown-Séquard syndrome c. Diffuse axonal injury d. Central cord syndrome
ANS: D Central cord syndrome is associated with cervical hyperextension/flexion injury and hematoma formation in the center of the cervical cord. This injury produces a motor and sensory deficit more pronounced in the upper extremities than in the lower extremities. Posterior cord syndrome is associated with cervical hyperextension injury with damage to the posterior column. This results in the loss of position sense, pressure, and vibration below the level of injury. Brown-Séquard syndrome is associated with damage to only one side of the cord. This produces loss of voluntary motor movement on the same side as the injury, with loss of pain, temperature, and sensation on the opposite side. Diffuse axonal injury (DAI) is a term used to describe prolonged posttraumatic coma that is not caused by a mass lesion, although DAI with mass lesions has been reported.
A nurse and a new graduate nurse are discussing the secondary survey of the trauma patient. The nurse asks the new graduate to identify the most important aspect of a secondary survey. Which response would indicate the new graduate nurse understood the information? a. Check circulatory status. b. Check electrolyte profile. c. Insert a urinary catheter. d. Obtain patient history.
ANS: D During the secondary survey, a head-to-toe approach is used to thoroughly examine each body region. The history is one of the most important aspects of the secondary survey. Additional interventions during the resuscitation phase involve placement of urinary and gastric catheters. During resuscitation from traumatic hemorrhagic shock, normalization of standard clinical parameters such as blood pressure, heart rate, and urine output are not adequate. Circulatory status is part of the primary survey.
Older trauma patients have a higher mortality than younger trauma patients. The nurse understands that this fact is probably related to what physiologic change? a. Deterioration of cerebral and motor skills b. Poor vision and hearing c. Diminished pain perception d. Limited physiologic reserve
ANS: D Older adults have limited ability to increase their heart rate in response to blood loss, obscuring one of the earliest signs of hypovolemia—tachycardia. Loss of physiologic reserve and the presence of preexisting medical conditions are likely to produce further conflicting hemodynamic data. An older patient's lack of physiologic reserve makes it imperative that early nutritional support is initiated.
A patient with severe traumatic brain injury has been admitted to the critical care unit. What is one intervention to minimize secondary brain injury? a. Hyperventilate the patient to keep PCO2 less than 30. b. Restrict fluids to keep central venous pressure less than 6 cm H2O. c. Maintain the patient's body temperature more than 37.5° C. d. Administer fluids to keep the 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.
A nurse and a nursing student are discussing management of the trauma patient. The nurse asks the student what the AVPU method is used for during the primary survey. Which response would indicate the new graduate nurse understood the information? a. Used to assess respiratory status b. Used to assess circulatory status c. Used to assess pain status d. Used to assess level of consciousness
ANS: D The AVPU method can be used to quickly describe the patient's level of consciousness: A: alert, V: responds to verbal stimuli, P: responds to painful stimuli, and U: unresponsive.
