Trauma Annual Lessons

Which injury can cause pain that radiates to the left shoulder?

A diaphragmatic injury results from large tears that cause herniation of the abdominal contents into the thorax. It causes abdominal or epigastric pain that radiates to the left shoulder (Kehr's sign). This type of pain is not a finding in tension pneumothorax, laryngeal injury, or bronchial injury.

Observation of which factor helps determine breathing effectiveness?

Assessment of breathing includes observation of skin color, noting such findings as cyanosis. Observation for tongue obstruction and loose teeth in the mouth are assessments to determine airway patency . Assessment of capillary refill time helps evaluate circulatory effectiveness.

Chest tube insertion is indicated for which patient?

Chest tube insertion is usually required for a patient who has a moderate to large pneumothorax (air occupies more than 15% of the pleural cavity), is symptomatic regardless of pneumothorax size, or requires mechanical ventilation. Chest tube insertion is not usually indicated for patients with flail chest, a diaphragmatic tear, or cardiac tamponade.

Which effect occurs in a patient with hypovolemic shock?

Hypovolemic shock results from inadequate fluid volume in the intravascular space. This reduces circulating volume and decreases venous return to the heart, which decreases preload. Decreased preload causes a decrease in cardiac output, which reduces oxygen delivery to the cells. Fluid shifts to the interstitial space in burns and sepsis.

Which intervention is immediately indicated for a finger injury from a high-pressure paint gun?

Prepare for Surgery This injury appears as a small pinhole in the fingertip but represents a serious, limb-threatening surgical emergency because material has been injected into the soft tissue. Immediate treatment requires debridement under general anesthesia. After debridement, splinting may be indicated. A subungual hematoma requires nail trephination, which releases blood under the nail and relieves the pressure.

A tracheostomy may be indicated for which injury?

Treatment of a laryngeal injury includes intubation, cricothyrotomy, or tracheostomy. Treatment of a bronchial injury includes bronchoscopy and possibly operative repair. Treatment of an esophageal injury requires urgent surgical repair. Treatment of a diaphragmatic injury requires gastric tube insertion and operative repair.

Which closed fracture site is associated with the smallest amount of blood loss?

With closed fractures, the maximum blood loss is 750 mL for an elbow fracture, 1,000 mL for an ankle fracture, 1,500 mL for a humerus fracture, and 2,000 mL for a tibia and fibula fracture.

Which statement accurately characterizes the use of hemodynamic monitoring devices in the management of a patient with shock?

central venous pressure monitoring is a useful tool for measuring the effectiveness of early goal-directed therapies in shock management. It indirectly measures circulating volume, cardiac pump effectiveness, and vascular tone by measuring the pressure on the right side of the heart. Central venous pressure normally ranges from 4 to 10 cm H2O. Invasive blood pressure monitoring should be used only in refractory shock. Frequent blood pressure measurements and examinations for signs of hypoperfusion should be used to monitor the patient in shock. Peripheral circulation changes, vasoactive drugs, and hypothermia affect the usefulness of pulse oximetry for monitoring a patient with shock. Arterial lines allow continuous blood pressure monitoring, which is useful when the patient is receiving vasoactive drugs. They also decrease the number of punctures required to obtain specimens for laboratory tests, which is particularly important for a patient with coagulopathies.

Which finding is a classic sign of cardiac tamponade?

lassic signs of cardiac tamponade are part of Beck's triad: muffled heart tones, hypotension, and jugular vein distention. Hemoptysis occurs in pulmonary contusion, bronchial injury, open pneumothorax, and aortic disruption.

Which hemodynamic finding supports the diagnosis of cardiogenic shock?

n cardiogenic shock, increased right atrial pressure is caused by the backup of fluids from the left side of the heart because the heart muscle cannot contract effectively and the left ventricle cannot empty completely. Cardiac output decreases when the heart fails as a pump. Systemic vascular resistance and heart rate increase, not decrease, to compensate for the reduced cardiac output.

f a patient presents with profound hypersensitivity and a systemic antigen-antibody response, what other response should you expect?

this patient is in anaphylactic shock, a form of distributive shock, which is caused by a profound hypersensitivity with a systemic antigen-antibody response. Activation of biochemical mediators results in increased capillary permeability, profound peripheral vasodilation, and smooth muscle constriction in the lungs. The reduction in venous tone and fluid extravasation causes decreased venous return and depressed myocardial function.

A patient has the highest risk of infection after being impaled with which object?

A patient who is impaled with any of these objects has a risk of infection. However, biologic substances, such as wood, carry an increased risk for infection. A. Knife B. Nail gunC. Wooden fence post D. Sewing needle

A patient with a burn injury is most at risk for which type of shock initially?

A patient with a burn injury is initially at risk for hypovolemic shock, resulting from inadequate fluid volume in the intravascular space. Fluid volume redistribution or third-space sequestration occurs when fluid shifts from the vasculature to the interstitial space. This results from changes in capillary permeability, as in burns or sepsis. The patient with a burn injury is not at risk for cardiogenic or obstructive shock. If sepsis occurs later, the patient could be at risk for septic shock, which is a form of distributive shock.

A patient with an isolated blunt cardiac injury is most at risk for which type of shock?

A patient with an isolated blunt cardiac injury is most at risk for cardiogenic shock because the myocardium may be contused, causing the heart's pumping action to fail. Hypovolemic, obstructive, and distributive shock do not result from damage to the myocardium.

Which patient is most likely to develop acute kidney injury?

A patient with anaphylactic shock is most likely to develop renal failure as a result of decreased renal perfusion. Although the combination of pregnancy and diabetes mellitus increase the risk of renal problems, a patient with anaphylaxis is at greater risk. Superficial partial thickness burns are unlikely to cause renal failure, especially if the patient is normovolemic. Dysrhythmias without a corresponding decrease in cardiac output are unlikely to result in renal failure.

A patient who sustained a crush injury of the chest develops cyanosis of the face and neck and subconjunctival and retinal hemorrhages. Which injury should you suspect?

A patient with cyanosis of the face and neck and subconjunctival and retinal hemorrhages after a crush injury to the chest is likely to have traumatic asphyxia. Patients with a pulmonary contusion experience dyspnea, hemoptysis, hypoxia, and possible chest wall abrasion or ecchymosis. Patients with flail chest exhibit pain, difficulty breathing, and paradoxical chest wall movement. Patients with cardiac tamponade exhibit hypotension, muffled heart tones, jugular vein distention, air hunger, agitation, and a decreased level of consciousness.

Which dislocation commonly results from seizure activity?

A posterior shoulder dislocation may occur in a patient with seizures when the arm is abducted and internally rotated. A wrist dislocation results from a fall on an outstretched hand. Acromioclavicular dislocation commonly affects athletes due to a fall or direct force on the point of the shoulder. Elbow dislocation results from a fall on an extended arm or from a longitudinal pull on the arm as a pediatric patient is jerked or lifted by a single arm (causing nursemaids elbow).

Which type of nerve injury causes an inability to extend the thumb in a hitchhiker's sign?

A radial nerve injury causes an inability to extend the thumb to make the hitchhiker's sign. Ulnar nerve damage causes a loss of pain perception in the tip of the little finger. Median nerve injury causes a loss of pain perception in the tip of the index finger. Peroneal nerve injury causes an inability to extend the great toe or foot.

A spiral fracture is associated with which mechanism of injury?

A spiral fracture is associated with a twisting force. In a young pediatric patient, especially an infant, a spiral fracture suggests maltreatment. An avulsion fracture results from the forceful contraction of a muscle mass that causes a bone fragment to tear away at the muscle insertion site. Blunt trauma to a flat bone is associated with a depressed fracture. A fall on an outstretched hand is a common mechanism of injury for forearm and wrist fractures, potentially causing a comminuted or greenstick fracture.

A patient with a sternal fracture is at increased risk for developing which complication?

A sternal fracture has a significant potential for underlying cardiac and pulmonary injury, including pulmonary contusion, blunt cardiac injury, and cardiac tamponade. A sternal fracture does not cause injury to the larynx, diaphragm, or esophagus.

A transverse fracture results from which mechanism?

A transverse fracture goes straight through the bone and results from a sharp, direct blow. A twisting torsion type of force can cause a spiral fracture. A compression force causes a greenstick fracture. Forceful contraction of a muscle mass causes an avulsion fracture.

Which patient needs the most emergent orthopedic intervention?

A. A patient who presents with a knee dislocation B. A patient who presents with an open tibial fracture C. A patient who presents with a shoulder dislocation D. A patient who presents with a femur fracture All of these patients require orthopedic intervention, but the patient with a knee dislocation has the most time-sensitive orthopedic injury. Knee dislocations are associated with an extremely high incidence of injury to the popliteal artery. The prompt reduction of this injury decreases the risk of vascular insufficiency in the affected limb.

Which finding should you expect in a 70-kg patient with an estimated blood loss of 1,700 mL?

A. Anxiety and confusion B. Increased pulse pressure C. Respiratory rate of 20 breaths per minute D. Urine output of 20 mL/hour Your correct answer: A Based on a blood loss of 30% to 40% (1,500 to 2,000 mL), this patient has class III hemorrhage. Signs of class III hemorrhage include anxiety and confusion (indicating decreased perfusion to the cerebral cortex and cerebral ischemia), decreased blood pressure, pulse rate above 120 beats per minute, decreased (narrowed) pulse pressure, respiratory rate of 30 to 40 breaths per minute, and urine output of 5 to 15 mL/hour.

Auscultation of a crunching, rasping sound over the pericardium indicates which injury

A. Cardiac injury B. Laryngeal injury C. Tracheal injury D. Bronchial injury Your correct answer: D Hamman's crunch is a crunching, rasping sound heard over the pericardium when air accumulates in the mediastinum. It results from bronchial and esophageal injuries. Cardiac, laryngeal, and tracheal injuries do not cause this finding.

Which injury should you suspect in a patient with abrasions or bruising on the anterior chest and cardiac dysrhythmias?

A. Pneumothorax B. Blunt cardiac injury C. Tracheal injury D. Esophageal injury Your correct answer: B Although trauma to the anterior chest can cause all of these injuries, the presence of dysrhythmias increases the likelihood of blunt cardiac injury. Patients with chest injuries between the midclavicular lines, clavicles, and costal margins require aggressive evaluation for cardiac involvement. Pneumothorax, tracheal injury, and esophageal injury do not cause dysrhythmias.

You are teaching a patient to walk with axillary crutches before discharge. Which finding suggests that he needs further instruction?

A. The patient places most of his body weight on the axillary crutch padding. B. The patient uses a three-point gait, moving the crutches and injured leg forward simultaneously. C. The patient keeps the tips of the crutches about 6 inches to the front and side with each step. D. The patient uses the crutches to go up and down stairs. The correct answer is: A A patient should place his or her weight on the hands and uninjured leg. The patient should avoid hanging from the crutches with the underarm on the axillary crutch padding, which can cause axillary nerve damage. The other findings reflect the appropriate crutch-walking technique

Which finding is expected in a patient with shock caused by an isolated spinal cord injury?

Acute spinal cord disruption from trauma or spinal anesthesia may cause neurogenic shock, a form of distributive shock, which inhibits or depresses the outflow from the vasomotor center in the medulla, causing the loss of sympathetic vasomotor regulation. Vasodilation and the loss of sympathetic tone occurs. The body cannot constrict the blood vessels. Venous blood flow to the heart decreases, which reduces cardiac output and blood pressure. Expected findings include hypotension, bradycardia, and warm, dry skin. Jugular venous distention is an unlikely finding.

Which intervention is appropriate for a patient with a flail chest?

After ensuring adequate oxygenation, the nurse must manage pain in a patient with a flail chest to promote adequate respiratory excursion and prevent complications such as pneumonia and atelectasis. In flail chest, fluids are limited because of associated pulmonary contusions and the potential development of acute respiratory distress syndrome. Surgical stabilization is indicated only in specific situations, such as when a patient fails to wean from the ventilator after achieving a partial resolution of the pulmonary contusion or when a patient's pulmonary function deteriorates despite aggressive clearance of bronchial secretions and adequate analgesia. No evidence indicates that this patient has pneumothorax or hemothorax, which would require chest tube insertion.

A patient reports a sudden, sharp pain from the heel to the back of the leg after running. Which injury should you suspect?

An Achilles tendon rupture can occur in start-and-stop sports during which a person steps off abruptly on the forefoot with the knee forced in extension. This injury is characterized by sharp pain that extends from the heel into the back of the leg. The patient may report hearing a loud crack or snap or feeling a sensation of something striking the posterior ankle. These findings do not occur in a quadriceps tear, heel fracture, or patellar dislocation.

An air embolus can cause which type of shock?

An air embolus can cause obstructive shock by obstructing flow from the right atrium to the lungs and preventing right ventricular emptying. Hypovolemic, distributive, and cardiogenic shock do not result from an obstruction.

Vasodilation and maldistribution of blood volume result from which disorder?

Anaphylaxis, a form of distributive shock, is a profound hypersensitivity with a systemic antigen-antibody response. Activation of biochemical mediators results in profound peripheral vasodilation, increased capillary permeability, maldistribution of blood volume, and smooth muscle constriction in the lungs. Pulmonary embolus and cardiac tamponade cause obstructive shock, and cardiomyopathy causes cardiogenic shock

A patient with a suspected aortic disruption is likely to display which finding?

Aortic disruption causes a discrepancy between the blood pressures in the right and left arms, increased blood pressure and pulses in the arms, and decreased or absent blood pressure and pulses in the legs. Bronchial and esophageal injuries produce Hamman's crunch (a crunching, rasping sound heard over the pericardium when air accumulates in the mediastinum).

When assessing for arterial injury, which factor should you consider?

Arterial injuries may not require repair if the existing collateral circulation prevents ischemia. These injuries are associated with high-impact and rapid-deceleration mechanisms. They may be difficult to discover because 10% to 15% of significant arterial disruptions present with detectable distal pulses. Nerve injury may result from compression caused by prolonged skeletal traction.

A patient with compartment syndrome undergoes arteriography to identify which cause of this disorder?

Arteriography can identify or rule out vasospasm, thrombus, embolus, or arterial trauma. It cannot identify nerve compression, muscle ischemia, or high compartment pressure. The diagnosis of compartment syndrome requires measuring the pressure in affected fascial compartments, using a syringe or catheter device.

Autotransfusion after chest tube insertion is contraindicated for which patient?

Autotransfusion is not appropriate when enteric contamination has occurred or is suspected (as in a ruptured diaphragm), infection is present, the patient has coagulopathies or hepatic or renal insufficiency, or the blood has been in the autotransfuser for more than 6 hours. Autotransfusion is indicated for wounds that are less than 4 to 6 hours old or are associated with significant intrathoracic blood loss (more than 350 mL in an adult). It is also indicated when homologous blood is not available and when a patient's religious convictions (Jehovah's Witnesses, for example) forbid homologous transfusion.

Which structure is a collection of specialized neural tissues that respond to small changes in vascular tone or pressure?

Baroreceptors are a collection of specialized neural tissues in the aortic arch and bifurcation of the common carotid arteries that sense decreased cardiac output and trigger sympathetic stimulation and peripheral vasoconstriction to try to increase circulating volume and maintain blood pressure. The hypothalamus secretes a corticotropin-releasing hormone, which stimulates the pituitary to release the adrenocorticotropic hormone. This causes the adrenal glands to release cortisol, which elevates the blood glucose level, causes renal retention of water and sodium, and suppresses the immune system. The adrenal medulla releases catecholamines (epinephrine and norepinephrine) when stimulated by the sympathetic nervous system in response to hypoperfusion. Aldosterone and antidiuretic hormones promote sodium reabsorption in the renal tubules to try to increase circulating volume and cardiac output.

A 70-kg patient who has lost 15 percent of his blood volume is likely to display which finding?

Based on a blood loss of up to 15 percent (750 mL), this patient has class I hemorrhage. With this degree of hemorrhage, findings typically include a normal or increased (widened) pulse pressure, heart rate of less than 100 beats per minute, respiratory rate of 14 to 20 breaths per minute, and a urine output of more than 30 mL/hour.

A multiple trauma patient with sustained blood loss is mildly anxious. He has a blood pressure of 120/90 mm Hg, a pulse of 110 beats per minute, and a respiratory rate of 22 breaths per minute. Based on these findings, what estimated percentage of blood loss has occurred?

Based on these findings, the patient's estimated blood loss is 15% to 30% (750 to 1,500 mL in a 70 kg patient) or a class II hemorrhage. With this degree of blood loss, expected findings include a normal blood pressure, narrowed pulse pressure, heart rate of more than 100 beats per minute, respiratory rate of 20 to 30 breaths per minute, and mild anxiety.

Twelve hours ago, a patient had a cast applied to a fractured forearm. Now, he presents to the emergency department with excruciating pain and swollen, cool, pale fingers. Which intervention is your priority?

Bivalve or remove the cast. Removing a constriction, such as a cast, is the priority intervention. This patient's signs and symptoms are characteristic of compartment syndrome. His cast may be compressing a fascial compartment, interrupting microvasculature circulation. If you suspect compartment syndrome, position the extremity level with the heart—not below or above it, which would increase or decrease the blood flow, respectively. Administering analgesics and consulting the orthopedic surgeon are appropriate interventions but do not take precedence over relieving the pressure on the affected compartment. Expect to assist with compartment pressure measurements and to prepare the patient for surgery if a fasciotomy is indicated.

Along with calcium, bone stores which mineral?

Bones store a number of minerals, including calcium and phosphorus. Bones do not store potassium, magnesium, or chloride.

Which disorder may cause hypovolemic shock?

Burns may cause hypovolemic shock because of plasma loss. Sepsis and anaphylaxis are common causes of distributive shock. Cardiogenic shock may result from myocardial infarction, severe myocardial contusion, dysrhythmias, ruptured papillary muscle, and other disorders.

Which disorder is a cause of cardiogenic shock?

Cardiogenic shock occurs when the heart fails to function adequately as a pump, such as with dysrhythmias or massive myocardial infarction. Obstructive shock results from a mechanical obstruction or compression of the great veins, pulmonary arteries, aorta, or the myocardium. Causes of obstructive shock include pulmonary embolus, pericardial tamponade, and tension pneumothorax.

After falling on an outstretched hand, a patient presents with an obviously deformed forearm. Her neurovascular status is intact. Which technique is appropriate for the initial immobilization of this injury?

Correct angulation before the injury is immobilized. Immobilization should include the joints above and below the injured area and should occur as soon as possible to minimize further damage. Initially, splint the injury as found. Traction splints are specific to femur fractures and are not indicated for this injury. If the neurovascular status is initially compromised, use gradual traction to promote the return of vascular or neurologic function before immobilization. Initially, correct angulation only if the resulting deformity prevents immobilization or causes neurovascular compromise.

Which manifestation is associated with cardiogenic shock?

Crackles, wheezes, or coarse breath sounds indicate pulmonary congestion, which can occur in cardiogenic shock. Shock commonly causes tachypnea when the body tries to blow off carbon dioxide and compensate for cellular acidosis. Patients with cardiogenic or obstructive shock may have full neck veins as a result of right-sided ventricular failure or increased intrathoracic pressure. Patients in cardiogenic shock have cool, clammy skin

A man, age 24, is brought to the emergency department after being in a motor vehicle collision. He was trapped in his vehicle for 45 minutes because his legs were pinned during the impact. Because of this patient's mechanism of injury and presenting injuries, the nurse should monitor for which condition?

Crush injuries can cause rhabdomyolysis due to muscle tissue damage. These injuries can also lead to hyperkalemia. Pyelonephritis is a consequence of a urinary tract infection and is unrelated to trauma. Septic shock results from an overwhelming infection. In a trauma patient, it may occur later but not on arrival in the emergency department.

A patient stabbed in the right lower thorax sustains a liver laceration. Based on the mechanism of injury, you should know that the patient may also have sustained which injury

Diaphragmatic injuries rarely occur alone and usually appear with other blunt thoracic injuries, trauma to the liver or spleen, or pelvic or long bone fractures. Most injuries affect the left side of the diaphragm. When injuries do occur on the right, they may be difficult to identify because of the liver. Based on the mechanism of injury, the patient is not likely to have sustained injury to the heart, aorta, or bronchi.

Emergency needle thoracentesis is a treatment for which type of shock?

Emergency needle thoracentesis is the appropriate emergent treatment for tension pneumothorax, which is a cause of obstructive shock. Needle thoracentesis is not used to manage cardiogenic, hypovolemic, or distributive shock.

For a patient with shock who sustained a traumatic brain injury without systemic hemorrhage, which mean arterial pressure should you maintain?

Evidence-based guidelines recommend maintaining a mean arterial pressure of 90 mm Hg during shock resuscitation for traumatic brain injury without a systemic hemorrhage. For an uncontrolled hemorrhage due to trauma, maintain a pressure of 40 mm Hg until bleeding is controlled. For all other shock states, maintain a pressure that exceeds 65 mm Hg.

Which bone fracture can damage the peroneal nerve, sciatic nerve, and popliteal artery?

Femur The complications of a femur fracture include damage to the peroneal nerve, sciatic nerve, and popliteal artery. The complications of a hip fracture include hypovolemic shock, avascular necrosis (with femoral head and neck fractures), and nonunion. The complications of a pelvic fracture include bladder, genital, and lumbosacral trauma; ruptured internal organs; sepsis; shock; and death. Because of its anatomical position and because it is not a weight-bearing bone, a distal fibula fracture is less likely to cause injury to these nerves and the popliteal artery.

The immobilization of which fracture depends on the patient's comfort and functional demands?

For a clavicle fracture, the immobilization (if any) should depend on the patients comfort and functional demands. The patient should rest the shoulder, avoiding activities that precipitate pain. A shoulder fracture requires immobilization with a sling-and-swathe bandage or shoulder immobilizer. A fracture of the proximal humerus generally requires a sling-and-swathe bandage, whereas a midshaft fracture is casted with a Y-shaped (sugar-tong) splint. An elbow fracture is splinted (if indicated) and placed in a sling.

If a patient's pH is less than 7.1, what is the most appropriate initial treatment?

For a patient with metabolic acidosis, adequate oxygenation and ventilation is the most appropriate initial treatment. After ensuring oxygenation and ventilation, obtain vascular access and begin fluid resuscitation with isotonic crystalloids because restoring perfusion is critical to terminating cellular anaerobic metabolism. Do not administer sodium bicarbonate before establishing adequate ventilation and fluid administration. Eventually, you may start an insulin infusion to maintain euglycemia, but this intervention should not occur in the initial phase of resuscitation.

The appropriate care of a patient with an open fracture includes which intervention?

For an open fracture with an obvious bone protrusion or a deep laceration, rinse the wound with sterile normal saline solution to remove gross contamination and then cover it with a dry sterile dressing. However, do not irrigate a puncture wound over a fracture site because this can force bacteria deeper into the wound. Elevate the injured extremity above the level of the heart. Position it at or below heart level if you suspect compartment syndrome.

A fracture of which bone does not always require anatomic alignment for healing?

Fractures that do not require anatomic alignment for healing include impacted fractures of the humeral neck, clavicular fractures (particularly in pediatric patients), and nonangulated femur fractures in pediatric patients. Wrist, hip, and elbow fractures require anatomic alignment for healing. Reduction is particularly important for intra-articular fractures, especially in weight-bearing bones.

Why do geriatric patients respond differently to shock than younger patients?

Geriatric patients have decreased cardiac and pulmonary reserves compared to younger patients. Geriatric patients do not have an increased circulating blood volume. The cardiovascular system is less able to respond to volume changes and less able to generate and maintain an altered cardiac output.

Sciatic nerve damage is associated with dislocation of which joint?

Hip dislocations are associated with sciatic nerve damage. Patellar dislocations are associated with hemarthrosis. Knee dislocations may cause peroneal and posterior tibial nerve damage. Ankle dislocations can lead to tibial artery compromise.

Which electrolyte imbalance occurs in an acute kidney injury?

In an acute kidney injury, hyperkalemia occurs when the kidneys lose the ability to excrete potassium. Other electrolyte imbalances associated with an acute kidney injury include hyperphosphatemia, hypocalcemia, and hyponatremia.

In a pediatric patient, which finding is an early sign of shock?

In pediatric patients, early clinical manifestations of shock include tachycardia (a nonspecific sign), tachypnea, pallor, cool mottled skin, and delayed capillary refill. Bradycardia, hypotension, and lethargy are late and ominous signs of decompensation.

What is the most sensitive sign of early shock in a pediatric patient?

In pediatric patients, the most sensitive sign of early shock is delayed capillary refill. Other early signs of shock include tachycardia, tachypnea, pallor, and cool, mottled skin. Hypotension is a late sign of shock in pediatric patients.

In which injury does air accumulation in the pleural space cause a loss of negative intrapleural pressure?

In pneumothorax, air accumulates in the pleural space, which results in partial or complete collapse of the lung as negative intrapleural pressure is lost. In hemothorax, free blood in the pleural space results from bleeding from the lung parenchyma, heart or major vessel injury, or injury to internal mammary arteries. In flail chest, fractures occur in two or more adjacent ribs in two or more places or the sternum is bilaterally detached from costal cartilage. This creates a free-floating, unstable segment that moves in opposition to normal chest wall movement. In a pulmonary contusion, the lung parenchyma is damaged, causing edema and hemorrhage.

Which intervention is the priority for a patient with septic shock?

In septic shock, a form of distributive shock, the priority intervention is fluid resuscitation with crystalloid or colloid-equivalent at 20 mL/kg. If the patient's hypotension does not respond to fluid resuscitation and the lactate level is more than 4.0 mg/dL, then vasopressors are used to maintain a mean arterial pressure of 65 mm Hg or more. Pericardiocentesis is used to manage cardiac tamponade, a cause of obstructive shock. Positioning the patient flat with the legs elevated is an intervention that helps counteract vasodilation and improve fluid return to the heart, which helps manage anaphylactic shock.

Hypotension is a likely finding in which injury?

In tension pneumothorax, the lung injury lets air enter the pleural space with inspiration but does not let it escape. This air accumulation forces the thoracic contents away from the injured side and causes a mediastinal shift towards the uninjured side, which results in hypotension. This finding does not occur in diaphragmatic injury, laryngeal injury, or pulmonary contusion.

When a patient is in the compensatory stage of shock, the body preferentially maintains blood flow to which organs?

In the compensatory stage of shock, the body preferentially maintains blood flow to the heart and brain. It diverts blood flow from the kidneys, gastrointestinal tract, and skin to improve cardiac output.

Which manifestation is an early sign of hypovolemic shock in adults?

Inadequate circulating blood volume causes cellular hypoxia and anaerobic metabolism, resulting in carbon dioxide retention. Tachypnea is an effort to decrease carbon dioxide and compensate for cellular acidosis. In early shock, the diastolic blood pressure rises. Tachycardia, not bradycardia, is an early sign of shock. A decreased level of consciousness may evolve as shock progresses. Early neurologic manifestations include anxiety, restlessness, and confusion

A woman, age 35, complains of a persistent, urgent need to void; urination of minimal urine; suprapubic pain; and pain during intercourse. The pain has continued for more than a month and worsens during menstruation. Urinalysis shows no red blood cells or bacteria in the urine. The nurse should suspect which disorder?

Interstitial cystitis produces recurring discomfort or pain in the bladder and the surrounding pelvic region as well as urinary urgency with minimal urine output. Pyelonephritis and urinary tract infection are unlikely because the patient's signs and symptoms have continued for more than a month and because urinalysis showed no bacteria in the urine. Urinary calculi are associated with hematuria, which this patient does not have.

During the circulation assessment, which intervention may the nurse need to perform

Interventions during the circulation assessment include controlling external bleeding, establishing two large-bore intravenous lines, and infusing warmed crystalloids to restore intravascular volume. Airway adjunct placement may occur during the airway assessment. Application of a three-sided occlusive dressing for an open pneumothorax or assistance with needle thoracentesis for a tension pneumothorax may occur during the breathing assessment.

After an assault, a patient presents to the emergency department with lower rib fractures and left flank tenderness. You should suspect injury to which organ?

Kidney The patient's history and presenting signs and symptoms indicate blunt trauma to the kidney. Bladder injuries typically are associated with pelvic fractures, liver injuries usually result from a direct blow to the right upper quadrant, and pancreatic injuries rarely occur with blunt trauma.

As lactic acid accumulates, which compensatory mechanism is initially triggered to maintain acid-base balance?

Lactic acid accumulation causes metabolic acidosis. As lactic acid accumulates, an increase in respiratory rate (tachypnea) is triggered initially to blow off excess carbon dioxide to maintain acid-base balance. The increased respiratory rate also maximizes oxygen delivery to the alveoli and cells. Shock triggers vasoconstriction to maintain systolic blood pressure, not to maintain acid-base balance. Gluconeogenesis is a compensatory mechanism that raises the blood glucose level, which makes more glucose available to the cells to meet their energy needs. However, it does not affect acid-base balance. The renin-angiotensin-aldosterone mechanism helps maintain the acid-base balance, but it is not an immediate response and may take up to an hour to occur.

Which type of shock is typically associated with acute spinal cord disruption from trauma or spinal anesthesia?

Neurogenic shock is a form of distributive shock, most often associated with acute spinal cord disruption from trauma or spinal anesthesia. Other causes of neurogenic shock include brain injury, hypoxia, depressant drugs, and hypoglycemia from insulin shock. Cardiogenic, obstructive, and hypovolemic shock are not associated with spinal cord disruption.

Which disorder is a cause of obstructive shock?

Obstructive shock results from mechanical obstruction or compression of the great veins, pulmonary arteries, aorta, or myocardium, which prevents adequate circulating volume. A pulmonary embolus prevents right ventricular emptying when a significant portion of the pulmonary artery lumen is blocked. Sepsis, anaphylaxis, and spinal cord injury are causes of distributive shock.

A closed fracture of which bone poses the greatest risk of hypovolemic shock?

Pelvic fractures pose the greatest risk of hypovolemic shock. A patient may lose 750 to 6,000 mL of blood from a pelvic fracture, 500 to 3,000 mL from a femur fracture, 250 to 2,000 mL from a tibia or fibula fracture, and 500 to 1,500 mL from a humerus fracture.

Radial nerve damage is associated with which fracture?

Radial nerve damage commonly accompanies fractures of the middle or distal portion of the humeral shaft. The complications of scapular fractures include injuries to the underlying ribs or viscera from the force required to cause the fracture. The complications of shoulder fractures include axillary nerve injuries and adhesive capsulitis (frozen shoulder). The complications of navicular (scaphoid) fractures include avascular necrosis or tissue death of the scaphoid from the loss of the blood supply.

A patient presents to the emergency department with an amputated hand from an industrial mishap. Which factor increases the likelihood of successful replantation?

Sharp, guillotine-like cuts have a better outcome than crush or avulsion injuries because the attached and amputated parts have less damage. The factors that affect successful replantation include the availability of a replantation team, amount of damage to the attached and amputated parts, method of preserving the amputated part, and time elapsed since the injury. Never place the amputated part directly on ice because the cell membranes can freeze, damaging the cells. Although tetanus status is not a factor in replantation success, you should assess the patient's tetanus status and administer tetanus immunization, as ordered. Bleeding must be controlled as part of the patient's initial stabilization in the emergency department, but bleeding that was controlled on arrival does not improve the likelihood of successful replantation.

Amputation by which mechanism has the best chance for a good outcome after replantation?

Sharp, guillotine-like cuts, such as from a meat slicer, have a better chance for a good outcome than crush or avulsion injuries because less damage occurs to the attached and amputated parts.

Which manifestation should you expect in a patient with shock?

Shock causes the liver to mobilize glycogen stores, resulting in an increased blood glucose level. In adults, urine output normally ranges from 0.5 to 1 mL/kg/hour. In shock, the blood urea nitrogen and creatinine levels increase as renal perfusion decreases. Also, bowel sounds become hypoactive or absent.

Which injury may require the insertion of a 14- or 16-gauge needle with a catheter into the second intercostal space at the midclavicular line on the injured side if a chest tube is not immediately available?

Tension pneumothorax requires immediate needle decompression, which involves insertion of a 14- or 16-gauge needle with a catheter into the second intercostal space at the midclavicular line on the injured side. Chest tube insertion must follow needle decompression because it is the definitive treatment for tension pneumothorax. If the physician was immediately available, a chest tube would be the first line of treatment. Hemothorax requires chest tube insertion and possibly autotransfusion. Cardiac tamponade requires pericardiocentesis (blood evacuation from the pericardial sac) as a lifesaving, temporizing procedure to improve cardiac function while the patient waits for surgery. Open pneumothorax requires the initial application of a three-sided occlusive dressing followed by chest tube insertion.

A mother brings her son, age 15, to the emergency department. He has been complaining of constant genital pain for 24 hours. The diagnosis is testicular torsion. What is the most serious possible complication?

Testicular torsion causes a vascular compromise of the testes within 4 to 6 hours and can lead to infarction, which results in atrophy and loss of spermiogenesis. Impotence, renal failure, and infection are not complications of testicular torsion.

Which substance is associated with immunosuppression in shock?

The adrenal glands release cortisol, which elevates the blood glucose level, causes renal retention of water and sodium, and suppresses the immune system. Glycogen, renin, and antidiuretic hormone are not associated with immunosuppression.

Which intervention is contraindicated in the initial management of an extremity injury?

The continuous application of an ice pack is contraindicated because prolonged cold may damage tissues. An effective regimen is to apply an ice pack for 20 minutes and then remove it for 30 minutes, repeating this at least three or four times in a day. The other interventions are appropriate in the initial management of an extremity injury.

The focused assessment with sonography for trauma (FAST) examination is highly reliable for detecting which injury?

The focused assessment with sonography for trauma examination is highly reliable for detecting pericardial effusion and hemothorax. It is a poor diagnostic tool for identifying hollow viscus or retroperitoneal injury. It cannot identify the source of bleeding or the injuries that may cause hemoperitoneum and is limited in detecting less than 250 mL of peritoneal fluid. It cannot identify blunt cardiac injury but can be used to detect cardiac tamponade.

While crossing the street, a patient is struck by a vehicle. He arrives in the emergency department with multiple lower extremity injuries. Which intervention is the priority?

The management of an orthopedic trauma patient begins with the assessment and stabilization of the airway, breathing, and circulation. The priority intervention for this patient is providing supplemental oxygen, preferably by a nonrebreather mask to maximize oxygen delivery. After stabilizing the airway, breathing, and circulation, rinse open fractures with sterile normal saline solution to remove gross contamination and cover them with a dry (not moist) sterile dressing. Administering analgesics and splinting a deformed extremity are important aspects of this patient's care, but neither is the priority intervention.

What is the functional unit of the kidneys?

The nephron is the functional unit of the kidneys. Each kidney contains about 1.2 million nephrons, which perform various functions related to secretion and reabsorption. The renal cortex is the outer portion of the kidney, and the renal medulla is the inner portion. The renal pelvis is the funnel-shaped, dilated proximal part of the ureter in the kidney. Its major function is to act as a funnel for urine flowing to the ureter.

Which factor places the patient at risk for distributive shock?

The presence of an invasive device, such as a urinary catheter, peripherally inserted central catheter, or feeding tube, increases the risk of sepsis, which is a cause of distributive shock. Mechanisms of injury to organs (such as the liver, spleen, or long bones) that can cause significant blood loss increase the risk of hypovolemic shock. Anticoagulants, such as warfarin (Coumadin), place the patient at risk for excessive blood loss from minor injuries, causing hypovolemic shock. Myocardial infarction that damages more than 40% of the left ventricle increases the risk of cardiogenic shock because the heart fails to pump normally.

Which intervention might you perform initially to manage a patient with obstructive shock?

The priority for obstructive shock is to identify the source of the obstruction and perform critical interventions to eliminate the obstruction. Emergency needle thoracentesis is the priority intervention for a patient with tension pneumothorax, a cause of obstructive shock. Fluid resuscitation, if needed, occurs after the obstruction has been identified and treated. Vasopressor administration is an intervention in septic shock if crystalloid infusion does not correct the patient's hypotension. Vasopressors may be prescribed to patients in neurogenic shock to restore an adequate mean arterial pressure if signs and symptoms of shock persist and other sources of hypotension have been ruled out. A patient with cardiogenic shock may need a mechanical device, such as an intra-aortic balloon pump and a ventricular assist device, to support the heart muscle.

Which parameter is a resuscitation endpoint for shock?

The resuscitation endpoints for shock include a mean arterial pressure greater than 65 mm Hg, a central venous pressure of 8 to 12 cm H20, and mixed venous oxygen saturation greater than 65%. A pH greater than 7.45 indicates alkalosis. The goal of managing septic shock is to normalize the pH, keeping it between 7.35 and 7.45.

Which heart chamber is the most vulnerable to blunt and penetrating trauma?

The right ventricle sits beneath the sternum, making it the heart chamber that is the most vulnerable to trauma.

Which volume of crystalloid bolus is appropriate for a pediatric patient with shock?

The standard volume of crystalloid infusion in pediatric patients with shock (or volume depletion) is 20 mL/kg. Packed red blood cells are replaced at 10 mL/kg in pediatric patients. The other choices are incorrect.

When caring for a multiple trauma patient with a narrowed pulse pressure and anxiety, you should consider which intervention the priority?

This patient has sustained a significant blood loss as exhibited by the narrowed pulse pressure and anxiety. The priority is to initiate large-caliber intravenous lines to administer crystalloids and blood products, as needed. This is done as part of the primary assessment. The patient requires high-flow oxygen via a nonrebreather mask, not via a nasal cannula. Although cardiac monitoring is important, it is not part of the primary assessment. Inserting a urinary catheter to monitor the resuscitation process is indicated after the primary assessment and appropriate interventions have been performed.

A man, age 29, arrives in the emergency department with severe scrotal pain that radiates to the abdomen, tenderness along the spermatic cord, fever, and urethral discharge. The complete blood count shows an elevated white blood cell count. Which disorder should the nurse suspect?

This patient's signs and symptoms are consistent with epididymitis. Testicular torsion does not produce a fever and urethral discharge. Priapism is a persistent, painful erection that is not associated with sexual desire, which this patient does not have. Prostatitis tends to cause pain in the lower back but not the scrotum.

A woman, age 31, complains of pain with urination, urinary frequency, and obvious hematuria. She reports being sexually active with only one partner and denies having vaginal discharge. On palpation, she has bilateral flank pain and abdominal tenderness. Her temperature is 100.4°F (38°C), and her urine is cloudy. Her last menstrual period was 2 weeks ago. This patient probably has which disorder?

This patient's signs and symptoms suggest a urinary tract infection or pyelonephritis. Urinary calculi can cause hematuria and dysuria, but the patient's fever and bilateral flank pain suggest a disorder other than urinary calculi. Sexually transmitted infections and interstitial cystitis are characterized by different presenting signs and symptoms.

Urinary calculi alter renal function by interfering with which factor?

Urinary calculi form in the kidneys and pass down the ureters into the bladder. They do not alter the blood flow or structural support of the kidneys. They do not affect the kidneys' ability to concentrate urine but do alter the urine outflow from the kidneys.

Which process keeps pressure in the glomerulus constant over a wide range of blood pressures?

Through autoregulation, dilation and constriction of the afferent arteriole (both processes, not just one) keep the pressure in the glomerulus constant despite a wide range of systolic blood pressures. The first step in urine production is glomerular filtration (plasma filtration in the renal corpuscles), which helps the kidneys rid the body of wastes and retain water and essential solutes.

Bronchial injury

Usually following blunt trauma to the chest and with 50% mortality within one hour, a pneumothorax associated with *persistent air leak* after tube placement suggests ______.

When fitting a patient for a cane, the elbow should be flexed to what degree?

When fitting a patient for an assistive device, such as crutches, a cane, or a walker, the elbow should be flexed 30 degrees.

For a patient with a complete joint disruption, which initial intervention is indicated?

administer Muscle Relaxants A complete joint disruption is a dislocation. The interventions for a dislocation include: administer analgesics, muscle relaxants, sedatives, or all three, as prescribed, to facilitate joint reduction; splint the joint in the position it is found; assess neurovascular status distal to the injury; evaluate for concurrent fractures; and consult an orthopedic surgeon. After these interventions, immobilize the joint and then measure the patient for crutches. (A walker may be used for an unsteady patient.)

For a patient with a gunshot wound, which intervention is appropriate?

erform a careful assessment, including neurovascular assessment, of all limbs to avoid overlooking other wounds. The wound's appearance does not necessarily reflect the amount of destruction to the underlying tissues. Tissue damage depends on the type of weapon, size and type of ammunition used, distance from the weapon, and part of the body injured. Always use forceps with rubber tips to handle projectiles to prevent scratching the projectiles, which makes the forensic evaluation difficult. Never label bullet wounds as entrance or exit wounds in documentation. Entrance wounds are not always smaller than exit wounds, and even forensic pathologists can struggle to differentiate entrance and exit wounds.

Which statement accurately characterizes shock in a pregnant patient?

n shock, the risk of fetal distress exists despite maternal stability. In fact, signs of fetal distress may be the first indications that the uterus and fetus are hypoperfused. Clinical findings associated with pregnancy may make the assessment of shock more difficult because the maternal heart rate and respiratory rate normally increase, and maternal vasodilation may cause systolic and diastolic blood pressures to decrease during pregnancy. Pregnancy is a hypervolemic state. The pregnant patient can remain normotensive with up to 1,500 mL of blood loss, so shock from volume loss does not occur as rapidly as in a pregnant patient. The patient is at increased risk for aspiration due to decreased gastric motility.

You are caring for a patient in the emergency department who is extremely anxious. She is short of breath and slightly nauseated. She has large red hives all over her body and reports that her skin is burning and itchy. She is flushed, hypotensive, and tachycardic. What type of shock should you suspect?

naphylactic shock is a form of distributive shock. Characteristics of anaphylactic shock include anxiety, shortness of breath, nausea, vomiting, and diarrhea. The patient may have hives or urticaria with sensations of burning and itching. Histamine release causes flushing, hypotension, and tachycardia. Septic, neurogenic, and hypovolemic shock do not cause these signs and symptoms.

When determining the appropriate splint for a patient with an angulated wrist fracture, which factor should you consider?

ommercially manufactured immobilization devices are acceptable as long as you follow basic splinting principles. Air splints are uncomfortable because they often stick to the skin, cause irritation, and are difficult to remove in patients with excess diaphoresis. If an air splint (not a traction splint) is not open on the distal end, pulse assessment and other neurovascular checks are difficult because they require deflating or unzipping the splint. Traction splints are used for fractures of the midshaft of the femur or upper third of the tibia and are not indicated for an angulated wrist fracture.

A patient who was stabbed in the chest exhibits a sucking or hissing sound on inspiration. Which intervention is indicated initially

pen pneumothorax (sucking chest wound) occurs when an opening in the chest is more than two-thirds the diameter of the trachea. Air moves preferentially into the chest through the chest wall (rather than through the trachea) and collects in the pleural space. Until more definitive treatment can be performed, apply a sterile, nonporous, three-sided occlusive dressing over the injury. This allows air to escape but prevents air from entering through the wound. Needle thoracentesis is used to treat tension pneumothorax. If this patient develops signs and symptoms of tension pneumothorax, remove the taped dressing immediately. Stabilize the knife and leave it in place. Never remove a penetrating object in the emergency department. Pericardiocentesis is the initial treatment for cardiac tamponade.

which finding is an early sign of decreased tissue perfusion?

restlessness is an early sign of decreased tissue perfusion. In shock, the brain shunts blood away from the cerebral cortex to maintain perfusion of vital centers in the brainstem. As perfusion decreases, the patient's level of consciousness progressively deteriorates from restlessness to confusion and then to obtundation and finally unresponsiveness.