Essential of Critical Care Nursing Chapter 17 Burns, Essentials of Critical Care Nursing Care of Traumatic Injury Ch. 9

Correct Answer: 4 Rationale 1: Sixteen thousand milliliters is the correct amount of IV fluid for resuscitation. The most commonly used formula is the Parkland formula, which recommends 4 mL/kg/% TBSA administered during the first 24 hours following a burn injury. Half of the total resuscitation volume is given in the first 8 hours. To solve the problem, first convert 220 pounds to kilograms: (220 ÷ 2.2 = 100 kg) 4 mL × 100 kg × 40% = 16,000 mL.

A middle-aged male patient weighing 220 pounds incurred burns to 40% of the total body surface area. Using the Parkland formula, calculate his fluid resuscitation needs for the first 24 hours. 1. 3,520 mL 2. 35,200 mL 3. 1,600 mL 4. 16,000 mL

Correct Answer: 1 Rationale 1: Hyperventilating the patient lowers the ICP by lowering the PaCO2 that is causing vasoconstriction 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.

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: 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.

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: 4 Rationale 1: Complaint of thirst would be expected due to dehydration. Rationale 2: Limited range of motion to the affected side is an expected finding. Rationale 3: A high pain rating is an expected finding. Rationale 4: Immediate signs of inhalation injury are changes to the mucosal lining of the oropharynx and larynx, including the presence of soot, hoarseness, edema, or blisters. The ABCs of resuscitation should be followed.

A patient comes to the emergency department with thermal burns to the left arm and shoulder. Which finding requires immediate attention by the nurse? 1. Complaint of excessive thirst 2. Loss of range of motion to the affected side 3. Pain rating of 8 on a 1 to 10 scale 4. Presence of coughing and hoarseness

Correct Answer: 1 Rationale 1: Circumferential extremity burns are at risk for developing compartment syndrome in which the pressure within the muscle compartments is greater than that within the microvasculature. These symptoms are characteristic of a loss of circulation due to compression of the blood vessels. Rationale 2: The ability to perform ADLs would likely not differ based on the location of the burn. Rationale 3: All hospitalized patients experiencing burns are at risk for nosocomial infections. Rationale 4: The symptoms of a deep vein thrombosis are more likely to be swelling, warmth, and pain in the extremity.

A patient in ICU with a burn circling the left upper leg suddenly experiences excruciating pain, pallor in the lower extremity, and loss of pedal pulse. The nurse would immediately notify the physician because this patient might be developing: 1. Compartment syndrome 2. Inability to perform ADLs 3. Nosocomial infection 4. A deep vein thrombosis

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 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? 1. Heart rate 120 2. Referred pain to the left shoulder 3. Upper left quadrant abdominal pain 4. Hematuria 5. Flank ecchymosis

Correct Answer: 3 Rationale 1: The whirlpool would provide no remedy for the impaired circulation. Rationale 2: Ace wraps would provide no remedy for the impaired circulation. Rationale 3: Circumferential burn wounds to the neck, chest, abdomen, and extremities are at risk for developing compartment syndrome. The burn eschar constricts the burned area at the same time that edema is causing subcutaneous fluid expansion. The net result is impaired circulation to the involved area. Compartment syndrome is prevented by performing an escharotomy whereby the physician uses a scalpel or electrocautery to cut through the eschar, which releases tension and permits blood flow to the area. Escharotomies are usually performed at the bedside. The nurse should be prepared to assist in draping and monitoring the patient during the procedure. Rationale 4: Skin grafting would provide no remedy for the impaired circulation.

A patient is complaining of increased pain to the area of a third-degree burn covering the entire arm. The nurse suspects compartment syndrome. For which intervention would the nurse prepare the patient? 1. Transportation to the whirlpool 2. Application of multiple ace wraps over the current gauze dressing 3. An escharotomy performed by the physician 4. Skin grafting performed by the physician

Correct Answer: 2 Rationale 1: Fentanyl would be used for pain management. Rationale 2: Anxiolytics such as lorazepam may be used if the patient is experiencing high anxiety. Rationale 3: Hydromorphone would be used for pain management. Rationale 4: Sertraline is an antidepressant, which can lower anxiety; however, it may take 4 weeks or more to be effective.

A patient is experiencing high levels of anxiety following a house fire. The nurse would administer which medication to help reduce the anxiety? 1. Fentanyl 2. Lorazepam 3. Hydromorphone 4. Sertraline

Correct Answer: 4 Rationale 1: This treatment will only open airways but not displace the carbon monoxide. Rationale 2: This treatment would be used for fluid resuscitation, not gas exchange treatment. Rationale 3: A bicarbonate drip is only used for severe metabolic acidosis that is not responsive to other treatment. Rationale 4: Carbon monoxide has a stronger affinity for hemoglobin than oxygen does so it displaces oxygen as it binds with the hemoglobin. This impairs oxygen transport and tissue perfusion. The treatment is high-flow 100% oxygen.

A patient rescued from a small house fire is brought to the emergency department. There is no burn injury to the skin, however laboratory results show a CO level of 22%. Which intervention would the nurse expect to implement? 1. Administer high-flow nebulizer treatment. 2. Infuse a fluid bolus of lactated Ringer's solution. 3. Begin a sodium bicarbonate drip. 4. Give 100% oxygen by mask.

Correct Answer: 31.5 Rationale : The upper anterior arm surface is a total of 9%. The lower anterior leg surface is 18%. The anterior face and neck is 4.5%. This patient's total body surface area burned is 31.5%

A patient sustained burns to the following body areas: both upper anterior arms, both lower anterior legs, and the anterior face and neck. The nurse uses the rule of nines to calculate this patient's total body surface area that is burned as being: Standard Text: Record your answer rounding to one decimal place.

Correct Answer: 1,2,3,4 Rationale 1: Burn resuscitation is considered successful when the patient has adequate urine output after 2 hours of fluids administered at maintenance rate. The urine output should be 0.5 to 1.0 mL/kg/hr. Rationale 2: Acceptable parameters include a heart rate less than 120 beats per minute. Rationale 3: A blood pressure that is normal to slightly hypertensive is evidence of successful resuscitation. Rationale 4: Clear lung sounds is evidence of successful resuscitation. Rationale 5: Bladder pressure is not used to assess effectiveness of resuscitative care.

A patient weighing 80 kg is receiving resuscitative care for a burn to 46% of total body surface area. What findings indicate that resuscitation is being effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Urine output 50 mL/hour 2. Heart rate 96 beats per minute 3. Blood pressure 138/88 mm Hg 4. Clear lung sounds 5. Bladder pressure 15 mm Hg

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.

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? 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 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.

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? 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: 1,2,3,4 Rationale 1: Burn injuries that should be referred to a burn center include burns to the face. Rationale 2: Burn injuries that should be referred to a burn center include burns to the hands. Rationale 3: Burn injuries that should be referred to a burn center include burns to major joints. Rationale 4: Burn injuries that should be referred to a burn center include burns to the perineum. Rationale 5: These burn injuries would not necessitate the patient to be transferred to a burn center.

After the initial assessment of burn injuries it is determined that the patient will be transferred to a burn center for care. What assessment findings contributed to this decision? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Burns on the face 2. Burns on the hands 3. Burns to both hips 4. Burn to the perineum 5. Burns to the upper left arm and lower right leg

Correct Answer: 2,3,5 Rationale 1: Older patients have a decreased sense of pain. Rationale 2: The older patient may delay seeking treatment for the burn due to a diminished sense of pain. Rationale 3: Older patient have thinner skin, so when they experience burn injuries they often get more severe burns at lower temperatures and in less time than younger patients. Rationale 4: Older adults with impaired hearing and not vision often do not have fire alarms that compensate for their impairment, they may not hear an alarm, and they may not be able to evacuate a burning building promptly. Rationale 5: Older adults are more likely to have concurrent respiratory problems (COPD, asthma, or lung cancer).

An 80-year-old patient is admitted for 39% TBSA burns. The nurse would assess for which risk factors that apply to this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Higher sensitivity to pain 2. Delay seeking treatment 3. Thinner skin 4. Impaired vision 5. Concurrent respiratory problems

Correct Answer: 4 Rationale 1: Providing humidified oxygen would be appropriate after an airway is secured. Rationale 2: Placing on a cardiac monitor would be appropriate after an airway is secured. Rationale 3: Obtaining intravenous access would be appropriate after an airway is secured. Rationale 4: This is the most appropriate first action because the first assessment of a burn patient, whether at the scene or in the emergency department, would be a primary trauma survey beginning with the ABCs (airway, breathing, circulation). In order to secure an airway, this patient may be prophylactically intubated because there are signs of progressing respiratory stress and airway edema related to the tachypnea, stridor, and presence of soot, which places the patient at increased risk for inhalation injury. Procuring a secure endotracheal tube is very important because it is very difficult to reintubate a burn patient due to severe airway edema and neck swelling.

An alert patient at the scene of an explosion has a respiratory rate of 24 breaths per minute, a faint stridor, and soot on the face. The patient's heart rate is 120 beats per minute. Which action would be most appropriate to implement first? 1. Administering humidified oxygen 2. Placing on a cardiac monitor 3. Inserting a large-bore angiocatheter 4. Prophylactically intubating the patient

Correct Answer: 2 Rationale 1: This would occur during the resuscitative phase due to large amount of fluid loss. Rationale 2: During the acute phase, fluid resuscitation is complete and the patient is at risk for sepsis and septic shock. Rationale 3: This would occur during the rehabilitative phase as healing is occurring. Rationale 4: Even though the presence of an indwelling urinary catheter can contribute to a urinary tract infection, it is not unique to the burn patient.

During the acute phase of burn injury, the patient has the risk of developing complications. The nurse would assess for the presence of: 1. Hypovolemic shock 2. Septic shock 3. Wound scarring 4. Urinary tract infection

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.

During the assessment of a patient with a suspected cardiac tamponade, the nurse should monitor for the development of: 1. Pulsus paradoxus 2. Muffled heart sounds 3. Hypotension 4. Flat jugular veins

Correct Answer: 2 Rationale 1: The TBSA percentage and details of how the burn occurred would also be important assessments but are done after the ABCs are completed. Rationale 2: Once the initial ABCs have been assessed, neurologic status should be examined. A burn patient should be awake and able to follow commands. Decreased neurologic status or unconsciousness may indicate anoxic injury or an additional neurologic injury. Rationale 3: Physical needs and assessments must be completed prior to psychologic needs. Rationale 4: This would be done after the airway has been secured.

Following establishment of an airway, adequate breathing, and circulation, the nurse would focus next on which assessment following a burn injury? 1. Determining total body surface area of the burn 2. A quick check of neurologic status 3. Psychologic trauma resulting from the incident 4. Details of how the injury occurred

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.

Immediate interventions for a patient with a sucking chest wound include: 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: 2 Rationale 1: Hypermetabolism is sustained for 9 to 12 months following burn injury. The patient's weight should be monitored closely throughout the rehabilitation phase. The patient may still require supplemental enteral nutrition or high- caloric nutritional supplements to maintain a positive energy balance. Rationale 2: "I should have regular osteoporosis screening" is correct and reflects understanding of discharge teaching. Large burn injuries have been associated with bone density losses and may be at increased risk for osteoporosis and pathologic fractures. Rationale 3: Thermoregulation disturbances continue throughout the rehabilitation phase and the patient may experience heat intolerance. Rationale 4: Following burn injury, there is an increased susceptibility to infection and appropriate precautions should be taken. This includes avoiding unnecessary exposure to people with colds or infections and maintaining up-to-date immunizations.

In preparing a patient for the rehabilitation phase of burn management, which statement reflects understanding of discharge teaching following a 6-month hospitalization? 1. "I need to begin cutting back on calories to avoid weight gain." 2. "I should have regular osteoporosis screening." 3. "I will likely not tolerate cold weather anymore." 4. "I must avoid getting a flu shot this year."

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.

In the patient with thoracic trauma, what would the nurse identify as potential problems? 1. Pleural effusion 2. Subcutaneous emphysema 3. Tracheal shift 4. Vertebral column injury 5. Bladder rupture

Correct Answer: 1 Rationale 1: "We should promote an increased oral fluid intake" is correct as a statement that requires further teaching. A nasogastric tube should be placed and suction applied to prevent aspiration; therefore, the patient will be NPO. This is also done to reduce the risk of the development of paralytic ileus. Rationale 2: A urinary catheter should be placed prior to administering large boluses of fluids. Rationale 3: This statement reflects an appropriate action and preparation. Rationale 4: Patients with major burns entering this phase should have large-bore intravenous access for fluid administration.

The burn unit nurse teaches a new staff nurse the priority nursing actions during the resuscitation phase of burn management. Which statement made by the inexperienced nurse indicates a need for further teaching? 1. "We should promote an increased oral fluid intake." 2. "A urinary catheter is usually inserted." 3. "I'll get a nasogastric tube and suction equipment ready." 4. "All patients should have a large-bore IV access if possible."

The critical care nurse is aware that the depth of burn injury is determined by the depth of tissue destruction and which other factors? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Duration of the burn exposure 2. Additional chronic medical conditions 3. Skin thickness 4. The cause of the burn 5. Body part of the burn injury

The critical care nurse is aware that the depth of burn injury is determined by the depth of tissue destruction and which other factors? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Duration of the burn exposure 2. Additional chronic medical conditions 3. Skin thickness 4. The cause of the burn 5. Body part of the burn injury

Correct Answer: 1,2 Rationale 1: Hypermetabolism causes a drop in body weight during the acute phase of a burn injury. Rationale 2: Hypermetabolism causes creatinine levels to increase during the acute phase of a burn injury. Rationale 3: Urine output is an indication of fluid and renal status effects and not a result of metabolic changes. Rationale 4: Abdominal pain is an indication of gastrointestinal status effects and not a result of metabolic changes. Rationale 5: Stridor is an indication of respiratory effects and not a result of metabolic changes.

The critical care nurse is concerned that a patient in the acute phase of a burn injury is experiencing metabolic changes 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. Drop in body weight 2. Elevated creatinine levels 3. Urine output of 20 mL/hr 4. Abdominal pain 5. Stridor

Correct Answer: 2,3,4,5 Rationale 1: With any type of shock, the patient would experience hypotension. Rationale 2: One cardiovascular change after a burn injury is peripheral extremity vascular compromise. Rationale 3: The most common cardiovascular change is hypovolemic burn shock. Rationale 4: One cardiovascular change after a burn injury is peripheral extremity vascular compromise. Rationale 5: One cardiovascular change after a burn injury is alterations in cardiac rhythm.

The intensive care nurse is assessing a patient for cardiovascular system changes related to a burn injury. Which findings are associated with a burn injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Hypertension 2. Altered capillary refill 3. Hypovolemic burn shock 4. Peripheral extremity vascular compromise 5. Cardiac dysrhythmias

Correct Answer: 1,2,4,5 Rationale 1: Thermal burns include scald injuries from exposure to steam. Rationale 2: Thermal burns include scald injuries from exposure to hot liquids. Rationale 3: Drain cleaner represents a chemical source. Rationale 4: Thermal burns include fire/flame injuries. Rationale 5: Thermal burns include contact/friction injuries.

The nurse providing an overview of burns to a community group is teaching the causes for thermal burns. These causes include: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Contact with steam 2. Exposure to hot liquids 3. Being splashed with drain cleaner 4. Stepping on hot charcoal 5. Friction injuries

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.

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: 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.

The nurse assesses a patient with a penetrating abdominal wound as a Class IV hemorrhage because of which findings? 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: Neuropathies can develop as a result of scar formation, edema, or improper positioning of splints or dressings. Rationale 2: The maturing burn scar is fragile and susceptible to wound breakdown from shearing and pressure. Rationale 3: Wound contractures occur as a result of scar formation over joints, which limit joint movement. Rationale 4: In areas of the wound with granulation tissue, collagen deposition can be disorganized, resulting in the development of a hypertrophic scar, which is erythematous and raised. Rationale 5: Osteomyelitis (bone infection) is not considered a typical wound or scar complication during the rehab phase.

The nurse has reviewed plans for wound and scar management for the rehabilitation phase following an extensive burn with a patient and explains about complications that can occur including: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Neuropathies 2. Wound breakdown 3. Contractures 4. Hypertrophic scarring 5. Osteomyelitis

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.

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: 1,2,3,4 Rationale 1: Debridement of major burn wounds involves cleaning the burn wound with warm water or sterile saline and antimicrobial soaps or wound cleansers. Rationale 2: Debridement of major burn wounds involves removing loose skin with gauze. Rationale 3: Debridement of major burn wounds involves trimming skin tags with scissors. Rationale 4: Debridement of major burn wounds involves shaving the hair around the wound. Rationale 5: The debrided wound is washed with warm water or normal saline.

The nurse is assisting with the initial debridement of a patient's burn wounds. What will be done during this debridement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Cleaning the wounds with warm water and wound cleanser 2. Removing loose skin with gauze 3. Trimming skin tags with scissors 4. Shaving the hair around the wound 5. Washing the debrided wound with hot water and liquid soap

Correct Answer: 1,2,3 Rationale 1: Electrical injury may result in cardiac dysrhythmias that can lead to cardiopulmonary arrest. Rationale 2: Electrical injuries may result in tissue destruction, which is not easily assessed. Rationale 3: Electrical injuries may result in bone destruction, which is not easily assessed. Rationale 4: Electrical injuries do not target the kidneys. Rationale 5: Electrical injuries do not target the lungs.

The nurse is caring for a patient who was brought into the emergency department after being struck by lightning. This patient's injuries will most likely be to which body areas? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Heart 2. Soft tissue 3. Bones 4. Kidneys 5. Lungs

Correct Answer: 1,2,3 Rationale 1: Chemical irritation of the alveolar tissue causes increased mucous production. Rationale 2: Chemical irritation of the alveolar tissue causes bronchospasm. Rationale 3: After 24 hours the patient's chest x-ray may show the development of patchy atelectasis. Rationale 4: Chest pain is not a manifestation of a lower airway injury. Rationale 5: Peripheral neuropathy is not a manifestation of a lower airway injury.

The nurse is caring for a patient who was in a house fire. The patient currently has a hoarse voice and has soot in the sputum. Over the next 24 hours, what will the patient experience as manifestations of a lower airway injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Increased mucous production 2. Bronchospasm 3. Alteration in breath sounds 4. Chest pain 5. Peripheral neuropathy

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.

The nurse is caring for a patient with a traumatic injury to the abdomen who is prescribed conservative, non-operative management. Which ongoing assessments should the nurse include in the plan of care? 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: 4 Rationale 1: This is not the immediate priority. Rationale 2: This is not the immediate priority. Rationale 3: This is not the immediate priority. Rationale 4: Based on the strategy of ABCs (airway, breathing, and circulation), fluid resuscitation is the greatest priority. The patient with heart problems must be closely monitored during fluid resuscitation and a balance must be maintained between providing adequate resuscitation to the tissues and further stressing the heart.

The nurse is caring for an older patient with a burn injury. Because preexisting health conditions influence how the older patient responds to the resuscitative treatment, the priority when caring for this patient would be: 1. Calculating nutritional needs 2. Coordinating physical therapy 3. Managing pain 4. Fluid resuscitation

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.

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? 1. Hoarse speech 2. Pain when swallowing 3. Coughing blood 4. Epistaxis 5. Periorbital edema

Correct Answer: 3 Rationale 1: It is easier for older people to take a shower because they do not have to risk slipping and falling while getting in and out of a bathtub. Rationale 2: Older people can have a decrease in memory and forget to test the water temperature. Rationale 3: Older and disabled individuals are at risk for scalding by hot bath water due to impaired sensation, slower reaction times, and decreased mobility. Rationale 4: Loss of skin elasticity is not a risk factor but could affect the severity.

The nurse is explaining to the granddaughter of an 85-year-old patient that older persons are at greater risk for scalding by hot water due to: 1. This age group's adversity to taking showers 2. An inclination to test the water's temperature 3. Overall slower reaction time 4. Loss of elasticity of skin tissue

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.

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? 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: 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.

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? 1. Full set of vital signs 2. Comfort measures 3. Head-to-toe assessment 4. Assessment of posterior surfaces 5. Exposure

Correct Answer: 3 Rationale 1: Fires caused by smoking are the leading cause of death in the older adult. Rationale 2: Scalds are not the leading cause of burn injuries in the older adult. Rationale 3: The picture of the pots and pans would be the best visual aid because approximately 3,000 older adults are injured in residential fires each year, with cooking fires being the leading cause of injuries. Rationale 4: Electrical fires are not the leading cause of burn injuries in the older adult.

The nurse plans a burn prevention program for older persons at a neighborhood association meeting. The visual aid developed by the nurse to emphasize the most common cause of burn injuries in an older adult would be: 1. A lit cigarette 2. A bathtub of hot water 3. Pots and pans on a stove 4. Frayed electrical wires

Correct Answer: 1,3,5 Rationale 1: The goals of wound management at this stage include decreasing the risk of developing compartment syndrome. Rationale 2: Comfort is an important issue for treatment, however it is a secondary measure. Rationale 3: The goals of wound management at this stage include preventing infection. Rationale 4: Reduction of scarring is an issue that can be addressed at a later time. Rationale 5: The goals of wound management at this stage are to decrease fluid and electrolyte losses.

The nurse plans care for a client with a major burn injury keeping in mind that the goals for initial burn wound management would include: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Decrease the risk of developing compartment syndrome. 2. Promote physical/psychological comfort. 3. Prevent infection. 4. Reduce the degree of scarring. 5. Decrease fluid and electrolyte loss.

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.

The nurse would include which activities when planning care to increase comfort for the intubated patient? 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: 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.

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 management, 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: 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.

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: 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

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 asthma

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.

What can the nurse do to convey comfort to a trauma patient? 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 Rationale 1: Contractures are prevented by performing exercises as prescribed by physical therapy. Rationale 2: Contractures are prevented by joint splinting. Rationale 3: Contractures are prevented by appropriate body positioning. Rationale 4: Range-of-motion exercises are used to treat contractures. Rationale 5: Surgery to release the joints is used to treat contractures that are unresponsive to therapy and not to prevent contractures from developing.

What interventions will the nurse plan to prevent the onset of contractures for a patient in the rehabilitation phase of burn care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Conduct exercises. 2. Splint joints. 3. Follow body positioning recommendations. 4. Perform range-of-motion exercises. 5. Schedule surgery to release the joints.

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.

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: 2 Rationale 1: Patients with large burns are more susceptible to infection and have difficulty regulating body temperature even after the burn wound is healed. Rationale 2: Healed burned areas are more susceptible to mechanical injury as a consequence of changes in the texture of the skin and decrease of sensory perception. Rationale 3: Sensation will eventually return but it may be altered. Rationale 4: Sun exposure should be avoided because burned areas are more susceptible to ultraviolet radiation.

What would the nurse teach a patient with a burn injury about skin changes that occur following a large burn? 1. Regulating body temperature returns with healing. 2. Healed burn areas are more susceptible to mechanical injury. 3. Sensory perception never returns once healing of a burn is complete. 4. Vitamin D from sun exposure facilitates the healing process.

When assessing zone of coagulation of a third-degree burn injury, the nurse would be alert for: 1. The presence of pain 2. Brisk capillary refill 3. Surface of the wound that is dry and firm 4. A bright red wound color

When assessing zone of coagulation of a third-degree burn injury, the nurse would be alert for: 1. The presence of pain 2. Brisk capillary refill 3. Surface of the wound that is dry and firm 4. A bright red wound color

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.

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: 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.

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: 1,3,4 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.

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? 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: 3 Rationale 1: The color of a minor burn is not deep reddish-brown. The skin will be slightly edematous in a minor burn. Rationale 2: Blisters will not form until after 24 hours, if at all. Rationale 3: Superficial, or first-degree burns, involve only the epidermal layer of the skin, leaving the skin intact. The involved skin is pink to red in color and slightly edematous. Rationale 4: These burns will heal without scarring in 3 to 6 days.

Which assessment finding by the nurse would be suggestive of a minor burn? 1. The involved skin is deep reddish-brown in color and edematous. 2. Blisters begin to form on the skin within the first hour of exposure. 3. The skin remains intact because only the epidermal layer is involved. 4. Scarring will be evident on the edges of the burn in a matter of hours.

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.

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: 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.

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: 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.

Which goals are appropriate for a patient with a traumatic injury and an ineffective breathing pattern? 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 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.

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: 2 Rationale 1: There is no smoke inhalation associated with an electrical burn. Rationale 2: Being trapped on an elevator during a fire in a building poses the greatest risk for an inhalation injury because of exposure to smoke or heat within an enclosed place. Rationale 3: There is no smoke inhalation associated with sunburn. Rationale 4: A scald injury is associated with hot water, not fire or smoke inhalation.

Which patient situation would present the greatest risk for an inhalation injury? The patient: 1. With a second-degree electrical burn of the hand 2. Trapped on an elevator during a fire in a building 3. With asthma who has extensive first-degree sunburn 4. With a scalding injury from liquid splashed on the legs

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.

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: 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.

Which risk factors could lead to the development of airway failure if not recognized while assessing the airway of a trauma patient? 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: 1 Rationale 1: Autografting is a procedure that involves removing thin slices of unburned skin from an unburned "donor" site and placing it on top of the excised burn wound as a permanent means of coverage. Rationale 2: Meshed autografts result in more scarring and are placed, when possible, on the back, buttocks, and thighs. Rationale 3: Cadaver skin (allograft) is often used to temporarily cover excised skin, and tissue typing is not performed. Therefore, allograft results in a temporary coverage until it sloughs from the wound bed. Rationale 4: Cultured autologous epithelial cells manufactured by Genzyme are the only commercially available permanent skin covering available in the United States. The cost of autologous epithelial autograft is considerable and use is reserved for patients with very large burns and few donor sites.

Which statement would the nurse use to explain skin covering procedures to a burn patient? 1. Autografts are permanent skin replacement for burns. 2. Meshed autografts are used for the face and hands. 3. Tissue typing is necessary for use of an allograft. 4. Cultured autologous epithelial cells provide a temporary wound covering.

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.

Which will the nurse assess when evaluating breathing in a patient suspected of having a thoracic trauma? 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: 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.

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? 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