Question 1

A patient is brought to the emergency department with gunshot wounds to the abdomen and lower extremities. To protect the chain of evidence for these injuries, what should the nurse do?

Accepted Answer

Removing the patient's clothing and placing them in a breathable bag will help preserve any potential evidence on the clothing. This should be done before any other interventions, including administering medications and starting IV access. The hands should also be bagged to preserve any potential evidence under the fingernails. Cutting off clothing and bathing the skin and wounds is not recommended as it can disturb evidence. All patient items, including clothing, should be secured until they can be collected by law enforcement.

Question 2

A patient has an estimated blood loss of 2 liters and a mean arterial pressure ranging between 30 and 40 mmHg. If this patient's hemodynamic status is not corrected, what should the nurse realize can occur?

Accepted Answer

Failure of the sodium-potassium pump can occur due to inadequate perfusion and oxygenation of tissues, leading to cellular dysfunction and potential organ failure. This is a consequence of significant blood loss and low mean arterial pressure, which compromise blood flow and oxygen delivery to cells.

Question 3

The nurse suspects that a patient diagnosed with a myocardial infarction is developing cardiogenic shock. What manifestation did the nurse assess to come to this conclusion?

Accepted Answer

Jugular vein distention is a manifestation of cardiogenic shock. It occurs due to back pressure from the heart, leading to venous congestion in the neck veins. Warm extremities, laryngospasm, and urticaria are not associated with cardiogenic shock.

Question 4

A patient diagnosed with hypovolemic shock is prescribed intravenous fluids while awaiting blood transfusions. Which solution does the nurse recognize would be best for this patient?

Accepted Answer

Ringer's lactate would be the best choice for a patient with hypovolemic shock as it contains electrolytes and can help restore the patient's fluid and electrolyte balance. Dextrose solutions do not provide the necessary electrolytes needed for a patient in shock.

Question 5

The nurse is providing medications to increase a patient's systemic vascular resistance. At which point will the nurse know that the patient has adequate tissue perfusion?

Accepted Answer

Mean arterial pressure of 60 mmHg is the minimum pressure required for adequate tissue perfusion.

Question 6

A female who was a victim of rape 6 months ago comes to an outpatient clinic for the treatment of posttraumatic stress disorder. Which data collected during the patient's assessment indicates a manifestation associated with this disorder?

Accepted Answer

Severe nightmares are a common manifestation of posttraumatic stress disorder and are therefore indicative of the diagnosis. The patient denying anger or shock and not needing drug or alcohol counseling may not necessarily be related to PTSD. The patient's statement regarding family support, while potentially beneficial to overall mental health, does not directly indicate PTSD.

Question 7

An adult patient who has died from traumatic injuries is an organ donor. What should the nurse do when caring for this patient?

Accepted Answer

Maintaining a systolic blood pressure of 90 mmHg is important to ensure adequate perfusion of organs for donation.

Question 8

A patient with a traumatic brain injury is being evaluated for brain death. Which findings should the nurse expect in this patient?

Accepted Answer

Brain death is characterized by the absence of brainstem reflexes, including the gag or coral reflex (A), the oculovestibular reflex (B), and the inability to breathe independently as shown by an apnea test with a PaCO2 threshold typically above 60 mmHg indicating a lack of respiratory drive (C). Toxic metabolic disorders (D) and response to deep stimuli (E) are not consistent with brain death criteria.

Question 9

The nurse identifies the problem of impaired physical mobility in a patient hospitalized with traumatic injuries. Which intervention should the nurse identify as appropriate for this patient?

Accepted Answer

Active range-of-motion exercises help maintain joint function and prevent muscle atrophy, which is appropriate for a patient with impaired physical mobility.

Question 10

A patient is admitted with severe facial injuries from a motor vehicle crash. For what should the nurse first assess this patient?

Accepted Answer

Severe facial injuries from a motor vehicle crash can cause airway obstruction due to swelling or displacement of tissues. Therefore, the nurse should first assess for signs of stridor, cough, or respiratory distress to ensure the patient's airway is not compromised.

Question 11

The spouse of a patient admitted with severe head injury tells the nurse that she believes her husband is going to recover because he is continuing to make movements without stimulation. What should the nurse explain to the spouse?

Accepted Answer

The nurse should explain to the spouse that movements made by a patient with severe head injury may be reflexive in nature and not necessarily an indicator of brain function. It is important to provide the spouse with accurate information and not give false hope.

Question 12

A patient admitted with multiple injuries is prescribed an intravenous colloid solution. Which solution would be appropriate for the nurse to infuse?

Accepted Answer

Intravenous colloid solutions are used to increase the volume of circulating blood in patients with multiple injuries. 25% albumin solution is a colloid solution that is commonly used for this purpose because it stays within the blood vessels longer than crystalloid solutions and helps to maintain blood volume and blood pressure. Normal saline (B) and dextrose 5% and water (D) are both crystalloid solutions and do not provide the same degree of volume expansion as colloid solutions. Dextrose 5% and 0.45% normal saline (C) is a hypotonic solution that is used for maintenance or replacement of body fluids, but it is not typically used for volume expansion in patients with significant injuries.

Question 13

The nurse is preparing to administer intravenous nitroglycerin to a patient diagnosed with cardiogenic shock. What should the nurse do when administering this medication?

Accepted Answer

Nitroglycerin is a potent medication that requires precise dosing. Using an infusion pump ensures that the medication is administered at a controlled rate, reducing the risk of adverse effects such as severe hypotension. PVC tubing should not be used to administer nitroglycerin as it can react with the medication and cause it to lose its potency. Nitroglycerin should be used within 24 hours of reconstitution. Patients receiving nitroglycerin should be monitored closely, and should not be allowed to get out of bed without assistance due to the risk of dizziness and falls.

Question 14

An older patient is diagnosed with E. coli in the bloodstream. If not treated, the nurse realizes this patient is at risk for developing which types of shock?

Accepted Answer

E. coli can cause sepsis, which is associated with distributive shock. In sepsis, there is an uncontrolled inflammatory response that can cause vasodilation and fluid shift from the blood vessels into the tissues, leading to low blood pressure and poor tissue perfusion. Obstructive shock is caused by a physical obstruction that impedes blood flow, hypovolemic shock is caused by a significant loss of blood or fluids, and anaphylactic shock is caused by a severe allergic reaction. While these types of shock may be seen in some patients with E. coli infections, distributive shock is the most likely.

Question 15

A patient with traumatic injuries has lost approximately 300 mL of blood. What should the nurse expect to assess in this patient?

Accepted Answer

A slight increase in heart rate is expected with a blood loss of approximately 300 mL. Nonpalpable peripheral pulses and narrowing pulse pressure are not typically seen until later stages of hypovolemic shock. An increase in blood glucose level is not typically seen with acute blood loss.

Question 16

A patient is diagnosed with a pneumothorax. The nurse realizes that unless this is treated, the patient is at risk for developing which type of shock?

Accepted Answer

A pneumothorax can lead to obstructive shock, as the trapped air in the pleural cavity can cause compression of the lung and lead to decreased oxygenation and cardiac output.

Question 17

The nurse wants to calculate a patient's mean arterial pressure. Which vital sign measurement should the nurse use to make this calculation?

Accepted Answer

Mean arterial pressure (MAP) is calculated using the patient's blood pressure. It takes into consideration the systolic and diastolic blood pressures as well as the pulse pressure. Temperature, respirations, and heart rate do not factor into the calculation of MAP.

Question 18

A patient diagnosed with shock is prescribed dobutamine (Dobutrex). Which finding indicates this medication has been effective?

Accepted Answer

Dobutamine is a medication that stimulates the heart to increase cardiac output, and therefore, increase heart rate. An increased heart rate indicates that the medication has been effective in reversing shock. Reduced heart rate, decreased respiratory rate, and decreased blood pressure would be indications that shock is not improving, and further interventions may be necessary.

Question 19

The nurse, caring for a patient who sustained a traumatic injury several days ago, notes that the patient is hypotensive, oliguric, and has cool, pale skin and acidosis. The nurse understands that these are manifestations of which type of shock?

Accepted Answer

These symptoms are indicative of hypovolemic shock, which occurs due to a significant loss of blood or fluid, leading to inadequate blood flow to organs. Hypotension (low blood pressure), oliguria (reduced urine output), cool and pale skin, and acidosis (build-up of acid in the body) are classic signs of this condition, especially following a traumatic injury that could involve blood loss.

Question 20

The nurse is planning care for a patient diagnosed with shock. Which intervention should the nurse include to address this patient's problem of anxiety?

Accepted Answer

Anxiety is a common psychological response to shock. To address this, the nurse should consider reducing stimuli and medicating for pain to promote comfort and decrease anxiety levels. Assessing blood pressure, heart rate, monitoring central venous pressure, and assessing bowel sounds are important interventions in the care of a patient with shock but do not specifically target the problem of anxiety.

Quiz 11: Nursing Care of Patients Experiencing Trauma and Shock