Deck 10: Nursing Care of People Experiencing Trauma and Shock

Question 1

The nurse suspects that a person is a victim of abuse. Which of the following would give the nurse this impression?

A)Injuries that do not correlate with the person's story of the injury.
B)Caring attitude between the person and significant other.
C)Evidence of adequate fluid intake.
D)Spontaneous movement of all four extremities.

Answer 1

Injuries that do not correlate with the person's story of the injury.

Question 2

A trauma person has multiple injuries and has lost approximately 40 per cent of circulating blood volume. This person is in which stage of shock?

A)Stage I.
B)Stage II.
C)Stage III.
D)Stage IV.

Answer 2

Stage II.

Question 3

The nurse recognises that which of the following is a clue to a possible violence-related injury?

A)Pattern burns.
B)Fractures with a history of trauma.
C)Confusion.
D)Head injuries.

Answer 3

Pattern burns.

Question 4

The nurse is admitting a trauma person. Which factors assist in determining the classification of trauma persons? (Select all that apply.)

A)Environment of the injury.
B)Vehicle speed.
C)Location of the injury.
D)Distance fallen.
E) None of the above

Question 5

A trauma person in stage II shock is demonstrating signs of pulmonary oedema. This person is manifesting which of the following?

A)Severe acute respiratory syndrome (SARS).
B)Heart failure.
C)Acute respiratory distress syndrome (ARDS).
D)Respiratory alkalosis.

Question 6

A critically injured trauma person needs immediate whole blood transfusions and has a blood type of AB+. The nurse realises that this person may receive which blood type?

A)AB- only.
B)Any type.
C)AB+ only.
D)A+ only.

Question 7

The nurse is determining a person's cardiac output. Which of the following completes the equation the nurse can use to make this assessment?

A)Systemic vascular resistance × stroke volume.
B)Systolic blood pressure × heart rate.
C)Mean arterial pressure × stroke volume.
D)Stroke volume × heart rate.

Question 8

The nurse recognises that which of the following is a manifestation of a haemolytic reaction resulting from a blood transfusion incompatibility?

A)Facial flushing.
B)Bradycardia.
C)Hypertension.
D)Hypothermia.

Question 9

A person is diagnosed as being in the warm phase of septic shock. The nurse will expect to see which of the following signs and symptoms in this person?

A)Pale skin.
B)Respirations rapid and shallow.
C)Alert and anxious.
D)Urine output less than 30 ml per hour.

Question 10

A nurse is caring for a person in hypovolemic shock. Which type of blood product should the nurse plan to administer?

A)Lipids.
B)Plasma.
C)Whole blood.
D)Platelets.

Question 11

The nurse recognises that the probability of a cervical spine injury decreases if the patient has which of the following?

A)Midline cervical spine tenderness.
B)Focal neurological defects.
C)Absence of intoxication.
D)Painful distracting injury.

Question 12

A person is evaluated for brain death. Which of the following diagnostic tests will need to be done to make this evaluation?

A)Cerebral CT scan.
B)ECG.
C)Glasgow Coma Scale.
D)EEG.

Question 13

A trauma victim presents with a deviated trachea, jugular vein distension and hypotension. What is the person most likely experiencing?

A)Blunt trauma to the chest.
B)Acceleration-deceleration injury.
C)Third space fluid shifts.
D)Tension pneumothorax.

Question 14

Which of the following are manifestations of moderate (Class III)haemorrhagic shock involving the loss of 1,800 ml of blood in an adult?

A)Pulse pressure decreased and heart rate less than 100 bpm.
B)Pulse pressure decreased and capillary refill mildly increased.
C)Blood pressure decreased and pulse pressure normal.
D)Heart rate greater than 120 bpm and capillary refill delayed.

Question 15

A person is receiving a blood transfusion. Which of the following action should the nurse take to ensure safe blood administration?

A)Administer the blood over a minimum of eight hours.
B)Monitor for signs of a reaction and take vital signs.
C)Inject an intravenous diuretic such as Frusemide (Lasix)through the blood tubing line.
D)Stay with the person throughout the transfusion.

Question 16

A person is brought into the emergency department with multiple stab wounds. These wounds are classified as which of the following?

A)Intentional.
B)Unintentional.
C)Accidental.
D)Related to a disease process.

Question 17

A person is prescribed an infusion of nitroprusside sodium (Nipride). Which action should the nurse take to ensure a safe infusion of this medication?

A)Protect the infusion bag from light by keeping the wrapping provided from the pharmacy on the bag.
B)Minimise adverse effects by administering adrenaline.
C)Perform initial vital observations every 30 minutes.
D)Mix with normal saline.

Question 18

A trauma person is being assessed with the Champion Revised Scoring System. What are the elements of this scoring system? (Select all that apply.)

A)Pulse pressure.
B)Mental status.
C)Pulse rate.
D)Glasgow Coma Scale.
E)Systolic blood pressure.

Question 19

A person is admitted with trauma to the integumentary system. Which of the following are types of skin trauma? (Select all that apply.)

A)Subcutaneous.
B)Avulsion.
C)Contusion.
D)Abrasion.

Question 20

A person in shock is prescribed a vasopressor medication. Which of the following would the nurse most likely administer to this person?

A)Nitroglycerin.
B)Dopamine.
C)Nitroprusside (Nipride).
D)Isoprenaline (Isuprel).