Chapter 20: Trauma and Surgical Management

Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome? a. Absence of pulse in affected extremity b. Pallor in the affected area c. Paresthesia in the affected area d. Severe, throbbing pain in the affected area

d. Severe, throbbing pain in the affected area

A patient has been admitted to the emergency department with a massive hemothorax. What action by the nurse takes priority? a. Place the patient on a cardiac monitor b. Prepare for rapid intubation c. Seal the wound with occlusive dressings d. Start 2 large bore IVs

d. Start 2 large bore IVs

During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (Select all that apply.) a. Chest wall ecchymosis b. Diminished or absent breath sounds c. Pink-tinged or blood secretions d. Signs of hypoxia on room air e. Paradoxical chest wall movement

a. Chest wall ecchymosis c. Pink-tinged or blood secretions d. Signs of hypoxia on room air

The nurse is assessing a patient for suspected alcohol withdrawal and identifies which signs and symptoms as suspicious? (Select all that apply.) A. Low body temperature B. Nausea, vomiting, diarrhea C. Irritable, confused, hallucinations D. Seizures E. Somnolent, difficult to arouse F. Hypotension and tachycardia

A and C Signs and symptoms of alcohol withdrawal include irritability, agitation, confusion, hallucinations and delusions, insomnia, anxiety and tremors, nausea, vomiting, diarrhea, diaphoresis, tachycardia and hypertension, fever, and seizures.

Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection? A fall from a 6-foot ladder onto the grass, A shotgun wound to the abdomen, A knife wound to the right chest, or A motor vehicle crash in which the driver hits the steering wheel

A shotgun wound to the abdomen

Prevention of hypothermia is crucial in caring for trauma patients. Which treatments are appropriate for preventing hypothermia? (Select all that apply.) A. Warm fluids and blood products before or during administration. B. Leave the patient's clothing on, even if wet. C. Cover the patient with an external warming device. D. Administer cool humidified oxygen. E. Warm the room in the emergency department and critical care unit.

A, B, and D. Oxygen should be warm and humidified to prevent hypothermia. External warming devices are effective in preventing or treating hypothermia. All of the patient's clothes should be removed so that the body can be inspected. Wet clothing increases the risk of hypothermia. After clothing is removed, the patient is warmed. Warming fluids and blood products reduces the risk of hypothermia. Warming the temperature in the rooms where care is provided is a strategy for preventing hypothermia.

Which three elements are commonly referred to as the "trauma triad of death?" (Select all that apply.) A. Hypothermia B. Acidosis C. Hypotension D. Tachycardia E. Coagulopathy

A, B, and E

What best defines the term traumatic injury?

Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events.

A 55-year-old trauma patient hit the steering wheel and has a cardiac contusion. Which are potential complications of the injury? (Select all that apply.) A. Myocardial ischemia B. Dysrhythmias C. Hypotension D. Flail chest

B, C, and D A flail chest is commonly associated with rib fractures, which are not present in this patient. Cardiac contusions present with signs and symptoms of ineffective heart functioning, including dysrhythmias, decreased cardiac output (i.e., hypotension), and myocardial ischemia that may progress to infarction.

Spinal cord injury causes a loss of sympathetic output, resulting in distributive shock with hypotension and bradycardia. Although blood pressure may respond to fluid resuscitation, what other therapy may be required to compensate for loss of sympathetic innervation? A. Glucocorticoids B. Proton pump inhibitors C. Colloids D. Vasopressors

D. Vasopressors Blood pressure may respond to IV fluids, but vasopressor therapy is often required to compensate for the loss of sympathetic innervation and resultant vasodilation. Colloid administration alone will not provide necessary vascular tone to support perfusion. Glucocorticoids are given in the early stages of spinal cord injury to reduce edema associated with injury and to improve outcomes. Proton pump inhibitors may be given to prevent stress ulcers.

What intervention would not be appropriate for a patient who is admitted with a suspected basilar skull fracture?

Insertion of a nasotracheal tube

An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center?

Level I

Which of the following interventions is a strategy to prevent fat embolism syndrome? a. Administer lipid-lowering statin medications. b. Intubate the patient early after the injury to provide mechanical ventilation. c. Provide prophylaxis with low-molecular weight heparin. d. Stabilize extremity fractures early.

d. Stabilize extremity fractures early.

A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED

is done quickly in the first few minutes to get a baseline assessment and establish priorities.

Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to achieve urine output of: a. 30 mL/hr. b. 50 mL/hr. c. 100 mL/hr. d. 300 mL/hr.

c. 100 mL/hr.

The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests? a. Arterial oxygen saturation b. Hourly urine output c. Mean arterial pressure d. Serum lactate levels

d. Serum lactate levels

The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of the car during a motor vehicle crash. The patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the provider and anticipates a. administration of lactated Ringer's solution (1 L) wide open. b. chest x-ray study to determine the etiology of the symptoms. c. endotracheal intubation and mechanical ventilation. d. needle thoracostomy and chest tube insertion.

d. needle thoracostomy and chest tube insertion.

Which interventions are appropriate to consider in the management of the geriatric trauma patient? (Select all that apply.) A. Ask the patient if he or she has fallen recently. B. Frequently assess for signs of acute delirium. C. Obtain a detailed list of current medications. D. Observe for signs of infection, primarily elevated temperature. E. Administer intravenous fluids rapidly to maintain blood pressure. F. Obtain a detailed medical history.

A, D, and E. Geriatric trauma patients provide unique challenges related to changes in phsyiology associated with aging. Obtaining a fall history is important because falls are the primary mechanism of traumatic injury in the older adult. Obtaining a complete past and current medical history, including a list of current medications, is essential. Older patients are at a higher risk of fluid overload becauses of age-related changes in the cardiovascular system. Fluid resuscitation should be monitored closely to avoid complications of overresuscitation. Monitor the patient for acute delirium, as delirum increases morbidity and mortality of the older trauma patient. The immune system is less responsive with aging, thus placing this patient at higher risk of infection and less pronounced changes in body temperature when infection is present. Brain mass decreases with aging; thus, changes in neurological exam may progress gradually.

A construction worker is admitted after falling approximately 15 feet from scaffolding. What diagnostic intervention does the nurse anticipate in the care of this trauma patient to evaluate sources of potential bleeding? A. FAST or E-FAST B. Complete metabolic laboratory test panel C. Chest radiograph D. Urinalysis

A. Diagnostic studies include CT, radiography, focused assessment with sonography for trauma (FAST), and extended FAST (E-FAST).E-FAST simply extends the ultrasound examination to evaluate possible injuries in the chest, looking for hemothorax and pneumothorax. In the context of traumatic injury, free fluid identified on the FAST examination is usually due to hemorrhage.

Your patient was a passenger in a motor vehicle crash yesterday and suffered an open fracture of the femur. His condition was stable until an hour ago, when he began to complain of shortness of breath. His heart rate is 104 beats/min, respiratory rate is 30 breaths/min, BP is 90/60 mm Hg, and temperature is now 38.4° C. You suspect that he A. has a fat embolism. B. has developed metabolic acidosis. C. is experiencing early multiple organ dysfunction syndrome (MODS). D. is developing systemic inflammatory response syndrome (SIRS).

A. has a fat embolism. These are classic signs and symptoms of a fat embolism. The history of a long-bone fracture adds to the evidence of a fat embolism. The patient may develop metabolic acidosis associated with poor oxygenation from the fat emboli. SIRS possibly progressing to MODS would also be a consequence of the fat emboli.

Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.) a. Crush injury to right arm b. Gunshot wound to the abdomen c. Lightning strike of the left arm and chest d. Pulmonary contusion and rib fracture e. Penetrating wound to both legs

a. Crush injury to right arm c. Lightning strike of the left arm and chest

A 72-year-old patient fractured his pelvis in a motor vehicle crash 2 days ago. He suddenly becomes anxious and short of breath. His respiratory rate is 34 breaths/min, and he is complaining of midsternal chest pain. His oxygen saturation drops to 75%. You suspect A. tension pneumothorax. B. myocardial infarction. C. pulmonary embolus. D. cardiac tamponade.

C. pulmonary embolus. The patient's history and respiratory signs and symptoms indicate pulmonary embolus. The patient's signs and symptoms do not suggest a cardiac tamonade; however, given the patient's age, he may be evaluated for a possible myocardial infarction. His mechanism of injury and his 2 days postinjury make a tension pneumothorax less likely.

To maintain the patient's airway, which interventions are appropriate to implement with a trauma patient who sustained a spinal cord injury? (Select all that apply.) A. Maintain complete spinal immobilization. B. Avoid hyperextension of the neck. C. Insert an oral airway if patient is alert. D. Observe respiratory pattern. E. Observe depth of ventilation. F. Elevate the head of bed 30 degrees.

B, E, and F. Maintaining a patent airway is an essential intervention in the care of the trauma patient. When the patient has a spinal cord injury, additional precautions are needed, including the following: (1) avoid hyperextension or rotation of the neck; (2) maintain spinal immobilization; (3) observe ventilatory effort, rate, depth, and effectiveness of breathing; (4) monitor motor and sensory function; and (5) anticipate the need for intubation and mechanical ventilation. Oral airways should not be inserted in an awake patient, as it will cause an airway obstruction. The patient's head of bed should remain flat, and spinal precautions should be taken.

Which patient symptom requires further urgent evaluation to address possible compartment syndrome? A. Swelling of the broken extremity B. Increasing pain C. Red discoloration of urine D. Dyspnea

B.

When obtaining report on a trauma pateint, which question would be helpful in determining potential injuries associated with the mechanism of injury? A. Was fluid resuscitation initiated? B. Was the patient wearing a seat belt? C. Where are the family members? D. Where was the patient in the car?

B. Was the patient wearing a seat belt? When obtaining report on a trauma patient, several questions should be asked to help determine potential complications associated with the mechanism of injury. It is especially important to ask where the patient was sitting in the car and whether he or she was wearing a seat belt. Asking the distance of a fall assists with understanding of complications from blunt forces. Information concerning the initiation of fluid resuscitation is helpful in determining tissue perfusion needs but may not provide insight into possible complications associated from the mechanism of injury. Information about the family is important for communication but does not assess etiology of injury.

The key purpose of the primary survey is to: A. Identify and treat all potential injuries B. Obtain a thorough head-to-toe examination of the patient C. Quickly identify and treat the greatest life-threatening emergencies D. Identify the need for additional consultation teams and resources

C. The primary survey is the most crucial assessment tool in trauma care. This rapid, 1- to 2-minute evaluation is designed to identify life-threatening injuries accurately, establish priorities, and provide simultaneous therapeutic interventions.

The primary priority for the critical care nurse with regard to the trauma patient is which of the following? A. Decrease the patient's risk for multiple organ dysfunction syndrome. B. Increase the physiological reserve of the trauma patient. C. Provide adequate oxygenation and tissue perfusion. D. Ensure adequate fluid resuscitation.

C. Provide adequate oxygenation and tissue perfusion. The priority is to maintain adequate oxygenation and tissue perfusion through effective fluid resuscitation and management of the patient's airway and breathing. Decreasing the patient's risk for MODS is achieved by ensuring tissue perfusion and oxygenation. Increasing physiological reserve is not an initial priority in the management of the trauma patient.

The nurse is working in the emergency department when a patient arrives who has experienced chest trauma. Which condition should the nurse be the most concerned with for this patient? A. Flail chest B. Cardiac tamponade C. Pulmonary contusion D. Hemothorax

C. Pulmonary contusion Pulmonary contusion as a result of blunt chest trauma increases the risk for development of pneumonia, acute lung injury, and/or ARDS. Cardiac tamponade is life threatening if untreated, but it is not a common complication after blunt chest trauma. Flail chest and hemothorax may result with blunt chest trauma, but they are not common causes of death.

A trauma patient with a fractured forearm complains of extreme, throbbing pain at the fracture site and paresthesia in the fingers. Upon further assessment, you note that the forearm is extremely edematous, and you are now having difficulty palpating a radial pulse. You notify the physician immediately because you suspect A. rhabdomyolysis. B. hypothermia. C. compartment syndrome. D. fat emboli.

C. compartment syndrome. These signs and symptoms are characteristic of late signs of compartment syndrome. Fat emboli are associated with long-bone fractures and typically manifest pulmonary symptoms. These signs and symptoms are characteristic of compartment syndrome, not hypothermia. Rhabdomyolysis is associated with a crush injury and compartment syndrome. A clinical sign that may be noted by the nurse is dark tea-colored urine.

Poor patient outcomes after a traumatic injury are associated with A. chest tube placement for treatment of a hemothorax. B. immediate decompression of a tension pneumothorax. C. massive transfusions of blood products. D. intraosseous cannulation for intravenous fluid administration.

C. massive transfusions of blood products. Current evidence suggests that patients receiving massive blood transfusions have poorer outcomes. Although a chest tube may be necessary in the treatment of trauma patients, it is not associated with poor patient outcomes. Immediate decompression of a tension pneumothorax is also not associated with poor patient outcomes. Intraosseous cannulation for intravenous fluid administration has not been shown to have adverse patient outcomes.

Which laboratory value indicates that the patient is under-resuscitated? A. Potassium (K+) of 6.1 mEq/L B. Calcium (Ca++) of 8.0 mg/dL C. Hematocrit (Hct) of 28.2% D. Lactate of 5 mmol/L

D ?

A restrained patient's status after a motor vehicle crash includes dyspnea, dysphagia, hoarseness, and complaints of severe chest pain. Upon assessment you note that the patient has weak femoral pulses. Which of the following complications and related diagnostic test should be considered? A. Pulmonary contusion and chest x-ray B. Liver laceration and focused assessment with sonography for trauma (FAST) C. Cardiac tamponade and pericardiocentesis D. Aortic dissection and aortogram

D. Aortic dissection and aortogram Signs of aortic disruption include weak femoral pulses, dysphagia, dyspnea, hoarseness, and severe pain. A chest x-ray study may demonstrate a widened mediastinum, tracheal deviation to the right, depressed left mainstem bronchus, first and second rib fractures, and left hemothorax. The diagnosis is confirmed by an aortogram. Cardiac tamponade presents with pulsus paradoxus and decreased cardiac output with poor venous return; a pericardiocentesis is the treatment of choice. Depending on the severity of the liver laceration, the pateint will present with right upper quadrant abdominal pain and tenderness and hypotension. FAST is used to diagnosis hepatic injury and intraabdominal bleeding. Pulmonary contusion will present primarily with signs and symptoms of poor oxygenation, and a chest x-ray may not be helpful in diagnosing this condition.

The trauma patient presenting with left lower rib fractures develops left upper quadrant tenderness, hypotension, and referred pain to the left shoulder. You suspect A. bowel obstruction. B. cardiac tamponade. C. pulmonary contusion. D. splenic injury.

D. splenic injury. Splenic injury occurs most often as a result of blunt trauma to the abdomen. However, penetrating trauma to the left upper quadrant of the abdomen or fracture of the anterior left lower ribs also contributes to splenic injuries. The patient may present with left upper quadrant tenderness, peritoneal irritation, and/or referred pain to the left shoulder (Kehr's sign). Hypotension or signs of hypovolemic shock may also be noted. The patient's injury and associated signs and symptoms suggest an injury to the spleen rather than cardiac, bowel, or pulmonary injury.

When providing information on trauma prevention, it is important to realize that individuals age 35 to 54 years are most likely to experience which type of trauma incident?

Poisonings from prescription or illegal drugs

Which interventions can the nurse implement to assist the patient's family in coping with the traumatic event? (Select all that apply.) a. Establish a family spokesperson and communication system. b. Ask the family about their normal coping mechanisms. c. Limit visitation to set times throughout the day. d. Coordinate a family conference. e. Determine how the family perceives the event

a. Establish a family spokesperson and communication system. b. Ask the family about their normal coping mechanisms. d. Coordinate a family conference. e. Determine how the family perceives the event

The trauma nurse understands which information related to the older trauma patient? (Select all that apply.) a. Falls are the leading cause of death in the older population. b. Physiologic capacity is an important predictor of outcome. c. Hypotension in the elderly can appear as normotension. d. Chronic diseases do not have much effect on the older trauma patient. e. Fractures to bones other than hips are uncommon from trauma.

a. Falls are the leading cause of death in the older population. b. Physiologic capacity is an important predictor of outcome. c. Hypotension in the elderly can appear as normotension.

Which of the following statements apply to trauma patients and their potential complications? (Select all that apply.) a. Indwelling urinary catheters are a source of infection. b. Patients often develop infection and sepsis secondary to central line catheters. c. Pneumonia is often an adverse outcome of mechanical ventilation. d. Wounds require sterile dressings to prevent infection.

a. Indwelling urinary catheters are a source of infection. b. Patients often develop infection and sepsis secondary to central line catheters. c. Pneumonia is often an adverse outcome of mechanical ventilation.

Which of the following findings require immediate nursing interventions in a patient with a traumatic brain injury? (Select all that apply.) a. Mean arterial pressure 48 mm Hg b. Elevated serum blood alcohol level c. Nonreactive pupils d. Respiratory rate of 10 breaths/min e. Open skull fracture

a. Mean arterial pressure 48 mm Hg c. Nonreactive pupils d. Respiratory rate of 10 breaths/min e. Open skull fracture

The nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration? a. Placement of an intraosseous catheter b. Placement of a central line c. Insertion of a femoral catheter by a trauma surgeon d. Rapid transfer to the operating room

a. Placement of an intraosseous catheter

Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.) a. Prevention of hypothermia b. Administration of fresh frozen plasma as ordered c. Administration of potassium as ordered d. Administration of calcium as ordered e. Monitoring CBC and coagulation studies

a. Prevention of hypothermia b. Administration of fresh frozen plasma as ordered d. Administration of calcium as ordered

A community-based external disaster is initiated after a tornado moved through the city. A nurse from the medical records review department arrives at the emergency department asking how to assist. The best response by a nurse working for the trauma center would be to a. assign the nurse administrative duties, such as obtaining patient demographic information. b. assign the nurse to a triage room with another nurse from the emergency department. c. thank the nurse but inform her to return to her department as her skill set is not a good match for patients' needs. d. have the nurse assist with transport of patients to procedural areas.

a. assign the nurse administrative duties, such as obtaining patient demographic information.

It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) a. ARDS b. Coagulopathies c. Dysrhythmias d. Myocardial dysfunction e. Fat embolism

b. Coagulopathies c. Dysrhythmias d. Myocardial dysfunction

A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What assessment data suggest the patient suffered tissue damage consistent with a blast injury? a. Blood pressure 82/60 mm Hg, heart rate 122 beats/min, respiratory rate 28 breaths/min b. Crackles (rales) on auscultation of bilateral lung fields c. Responsive only to painful stimuli d. Irregular heart rate and rhythm

b. Crackles (rales) on auscultation of bilateral lung fields

Which of the following statements about mass casualty triage during a disaster is true? a. Priority treatments and interventions focus primarily on young victims. b. Disaster victims with the greatest chances for survival receive priority for treatment. c. Once interventions have been initiated, health care providers cannot stop the treatment of disaster victims. d. Color-coded systems in which green indicates the patient of greatest need are used during disasters.

b. Disaster victims with the greatest chances for survival receive priority for treatment.

Which of the following statements are true regarding fluid resuscitation during the care of a trauma patient? (Select all that apply.) a. 5% Dextrose is recommended for rapid crystalloid infusion. b. IV fluids may need to be warmed to prevent hypothermia. c. Massive transfusions should be avoided to improve patient outcomes. d. Only fully crossmatched blood products are administered. e. Hypertonic saline solutions are often used during initial resuscitation.

b. IV fluids may need to be warmed to prevent hypothermia. c. Massive transfusions should be avoided to improve patient outcomes

During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent a. disseminated intravascular coagulation. b. multisystem organ dysfunction. c. septic shock. d. wound infection.

b. multisystem organ dysfunction.

Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent a. catheter-associated infection. b. venous thromboembolism. c. fat embolism. d. nosocomial pneumonia.

b. venous thromboembolism.

Which of the following patients have the greatest risk of developing acute respiratory distress syndrome (ARDS) after traumatic injury? a. A patient who has a closed head injury with a decreased level of consciousness b. A patient who has a fractured femur and is currently in traction c. A patient who has received large volumes of fluid and/or blood replacement d. A patient who has underlying chronic obstructive pulmonary disease

c. A patient who has received large volumes of fluid and/or blood replacement

The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient smells of alcohol and begins to vomit in the ED. What intervention is most appropriate?

c. Prepare to suction the oropharynx while maintaining cervical spine immobilization.

The nurse working in a trauma center administers blood products to a severely hemorrhaging trauma patient in a 1:1:1 ratio. Which blood products does the nurse include in this transfusion protocol? (Select all that apply.) a. Whole blood b. Universal donor blood only c. Red blood cells d. Platelets e. Plasma

c. Red blood cells d. Platelets e. Plasma

A near-infrared spectroscopy (NIRS) probe is placed in a trauma patient during the resuscitation phase to: a. assess severity of metabolic acidosis. b. determine intraperitoneal bleeding. c. determine tissue oxygenation. d. prevent complications of over-resuscitation.

c. determine tissue oxygenation.

In the trauma patient, symptoms of decreased cardiac output are most commonly caused by a. cardiac contusion. b. cardiogenic shock. c. hypovolemia. d. pericardial tamponade.

c. hypovolemia.