Deck 9: Care of the Patient Following Traumatic Injury

Question 1

What should the nurse expect to assess in a patient with a tension pneumothorax?
1) Tracheal deviation to the unaffected side
2) Bilateral equal chest movement
3) Decreased muscular effort by chest muscles
4) Decreasing central venous pressure (CVP)

Answer 1

1
Explanation: 1. As air accumulates on the pleural space with no place to escape, the affected lung collapses and the resulting increase on intrathoracic pressure puts pressure on the trachea, which causes displacement to the unaffected side.
2. Normal breathing is bilaterally equal. In a tension pneumothorax, one or more areas of the lung tissue collapses and does not expand, thus limiting the chest movement on that side. Therefore, the movement is bilaterally unequal.
3. Increased muscle effort will be the response to decreasing lung activity. Extra muscles of the chest are called into place to try to increase the effort to move the air within the lung tissues.
4. The CVP will increase to try to compensate for decreased pulmonary perfusion from a decrease in the surface area for oxygen to be exchanged.

Question 2

The mother of a patient just admitted with a spinal cord injury is asking if the patient will be given steroids. How should the nurse explain the role of steroids in treating spinal cord injuries?
1) Steroids will make the patient feel better overall and retain muscle strength due to its "muscle-bulking" effects.
2) Steroids have few side effects and remove all symptoms while healing the problem.
3) Steroids can lead to "road rage and anger outbursts" and therefore are avoided except under extreme emergencies.
4) Steroids have not been used recently because of possible adverse outcomes.

Answer 2

4
Explanation: 1. This is not the reason for using steroids in the patient with a spinal cord injury.
2. These drugs do have some major side effects, such as hyperglycemia, hypertension, redistribution of fat pads, and edema, as well as others that can be life threatening.
3. This is not a concern for the patient with a spinal cord injury.
4. Steroid therapy has been very controversial over the last couple of decades, and while occasionally still used in some institutions, evidence recommends against steroid use in light of lack of evidence and potential for adverse outcomes.

Question 3

A patient with a traumatic abdominal injury is prescribed conservative, nonoperative management. Which ongoing assessments should the nurse include in the plan of care? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Hourly vital signs
2) Assessment of the degree and type of guarding or rigidity
3) Hourly CVP readings
4) ECG changes for bradycardia and widening QRS
5) Widening pulse pressure

Answer 3

1, 2, 3
Explanation: 1. This would be done in the patient with a traumatic abdominal injury to assess for peritonitis.
2. This would be done in the patient with a traumatic abdominal injury to assess for peritonitis.
3. This would be done to assess fluid status and the onset of hypovolemic shock in the patient with a traumatic abdominal injury.
4. The ECG will show tachycardia from hypovolemia. Widening QRS show slowed conduction in the ventricles and would not be a sign of abdominal distress.
5. Widening pulse pressure is not seen in the patient with traumatic abdominal injury.

Question 4

What should the nurse assess when evaluating breathing in a patient suspected of having thoracic trauma? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Jugular vein distention
2) Symmetry of chest movement bilaterally
3) Chest movements that rise and fall with breathing effort
4) Respiratory rate, pattern, and effort
5) Peripheral skin coloring

Question 5

Which complication should the nurse plan care for a patient recovering from a pulmonary contusion?
1) Pneumonia
2) Tension pneumothorax
3) Flail chest
4) Pulmonary edema

Question 6

Which goals are appropriate for a patient with a traumatic injury and an ineffective breathing pattern? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Provide oxygen 100% therapy through a nonrebreather mask.
2) Restore the normal breathing pattern.
3) Maintain a calm environment to decrease oxygen demands.
4) Prevent sepsis.
5) Maintain balanced hydration.

Question 7

When discussing hemorrhagic shock with a nursing class, which statement by a student indicates to the nurse educator that additional teaching is required?
1) Blood loss into the abdominal cavity can lead to hypovolemic shock.
2) Septic shock is more common than hemorrhagic shock due to nosocomial infections.
3) When fluids shift into the interstitial spaces, the loss of vascular fluids can lead to hypovolemic shock.
4) Hemorrhagic shock symptoms include tachycardia, dyspnea, and hypotension.

Question 8

A nurse notes that a patient with a traumatic brain injury is having a rapid decline in level of consciousness. What should the nurse do to help this patient?
1) Provide brief hyperventilation.
2) Take measures to increase intracranial pressures by Trendelenburg positioning.
3) Prepare for emergency surgical repair.
4) Contact the family to come say their last words with the patient.

Question 9

Which risk factor could lead to the development of airway failure if not recognized while assessing the airway of a trauma patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Chest wall injury
2) Displacement of the trachea (tracheal shift)
3) Aspiration of gastric contents
4) Foreign object occlusion of the throat/mouth
5) Swelling of soft tissue in the throat

Question 10

What activity should the nurse implement under the A section of assessment priorities when admitting a patient with a suspected spinal cord injury?
1) Using a manual ventilation bag
2) Applying heated blankets
3) Using the jaw thrust maneuver
4) Assessing for history of asthma

Question 11

Which interventions should the nurse implement for a patient with a sucking chest wound? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Administer pain medication.
2) Continue to monitor pulse oximetry and respiratory characteristics.
3) Prepare for emergency intubation.
4) Prepare the patient for chest tube insertion.
5) Apply a dressing that is taped on three sides.

Question 12

A patient arrives in the emergency department with a flail chest after a motor vehicle crash (MVC) in which the patient's chest hit the steering wheel. What should the nurse realize this injury is due to?
1) Blunt trauma from internal forces caused by acceleration
2) Blunt trauma from external forces caused by deceleration
3) Penetrating trauma from external forces caused by deceleration
4) Penetrating trauma from internal forces caused by acceleration

Question 13

A patient is being treated for cardiac tamponade. What should the nurse consider as a reason for the health problem to recur?
1) Fluid or blood continues to accumulate in the pericardial sac.
2) The cause of the tamponade was persistent hypertension.
3) Treatment by needle aspiration of the fluid in the sac is performed.
4) A pericardial window is surgically created.

Question 14

When performing a quick assessment to identify life-threatening problems in a trauma patient, the nurse should include which assessments under the D-Disability section? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Ability to respond to painful stimuli
2) Vital signs
3) Ability to respond to verbal command
4) Level of consciousness or unconsciousness
5) Oxygen saturation levels

Question 15

Which nursing assessment should have highest priority for early airway management of a trauma patient?
1) Ask the patient to state his or her name.
2) Assess increasing intracranial pressure (ICP) with facial fractures.
3) Prepare for emergency tracheostomy.
4) Perform a computerized tomography (CT) scan of tissues of the neck.

Question 16

Which assessment finding indicates that a patient with a traumatic injury is having problems with breathing rather than difficulty maintaining an airway?
1) Pain with swallowing, coughing, or hemoptysis
2) Chest pain on inspiration
3) Popping sound (crepitus) in the throat when touching the skin by the trachea
4) Hoarseness when talking

Question 17

Which goal should receive the highest priority when caring for the patient with a cervical spine injury?
1) Relieve muscle spasm pain.
2) Maintain cervical alignment.
3) Support respiratory effort and prevent atelectasis.
4) Promote hypothermia.

Question 18

During the assessment of a patient with a suspected cardiac tamponade, for what should the nurse monitor? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Pulsus paradoxus
2) Muffled heart sounds
3) Hypotension
4) Flat jugular veins
5) Bounding peripheral pulses

Question 19

When managing shock, which statement is incorrect when comparing the level or classification of shock to the drug treatment?
1) Class I-treated with blood products
2) Class II-treated with isotonic fluids
3) Class III-treated with isotonic fluids and blood products
4) Class IV-treated with blood and fluids

Question 20

Which patient assessment data supports an open traumatic injury?
1) A closed hip fracture that was caused by a fall
2) A gunshot wound without penetration of the bullet due to the bullet-proof vest
3) Near-drowning after falling through a frozen lake
4) Burns over 30% of the body from a house fire

Question 21

A patient is brought to the emergency department after being bitten and dragged by a large dog while jogging in the morning. When planning care for this patient, on which forces should the nurse focus as the reason for this patient's injuries? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Stress
2) Electrical
3) Penetrating
4) Mechanical
5) Deceleration

Question 22

The charge nurse delegates the completion of a secondary survey of a patient with traumatic injuries to a nurse being oriented to the emergency department. What should the charge nurse remind the new colleague to complete? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) History
2) Vital signs
3) Comfort measures
4) Head-to-toe assessment
5) Nasogastric tube insertion

Question 23

A patient with massive injuries to the head and chest has died. The family is in the hallway waiting to see the patient. What can the nurse do to prepare the family to be with the patient at this time? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Remove blood-soaked bed sheets and gown.
2) Have at least one of the patient's hands readily available for the family to touch.
3) Place the stretcher in the low position.
4) Turn one dim light on in the room.
5) Leave the family to visit with the patient.

Question 24

A patient with a penetrating abdominal wound is identified as having a Class IV hemorrhage. What should the nurse expect to assess? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Heart rate 160
2) Respiratory rate 28
3) Mean arterial pressure 50
4) Capillary refill 5 seconds
5) Mild decrease in urine output

Question 25

The nurse assists the health care professional with rapid sequence intubation of a patient with severe traumatic injuries. Which agents should the nurse have available for this procedure? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Repolarizing
2) Depolarizing
3) Anesthetizing
4) Infection control
5) Pain management

Question 26

A patient receives emergency care for maxillofacial injuries from a motor vehicle crash. What assessment finding should indicate to the nurse that the patient sustained laryngeal trauma? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Hoarse speech
2) Pain when swallowing
3) Coughing blood
4) Epistaxis
5) Periorbital edema

Question 27

A patient is admitted with injuries sustained from a skiing accident. While completing the primary survey, the nurse suspects the patient has an injury to the spleen because of which findings? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Heart rate 120
2) Referred pain to the left shoulder
3) Upper left quadrant abdominal pain
4) Hematuria
5) Flank ecchymosis

Question 28

For which situation should the nurse plan to prepare a patient with abdominal trauma for surgery?
1) A suspected splenic injury having received 1 unit of blood
2) A Grade III liver injury with stable vital signs
3) A contusion to the kidney with a stable H & H
4) A pelvic fracture with muscle rigidity of the abdominal wall

Question 29

A patient with a C6 spinal cord injury who received several liters of intravenous fluid continues to have a blood pressure of 78/50 mm Hg. What should the nurse anticipate being prescribed for this patient?
1) Steroids
2) Beta blocker
3) Norepinephrine
4) Packed red blood cells

Question 30

Which activities should the nurse plan to increase comfort for a patient who is intubated? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Speak directly to the patient by looking into the patient's eyes.
2) Keep the patient sedated, and let the patient sleep when giving care.
3) Give additional pain medication whenever restlessness is noted.
4) Establish a communication method that does not require talking.
5) Keep the family at the bedside to interpret the patient's needs.

Question 31

An unconscious patient is brought to the emergency department. During the primary survey, the patient begins to moan when the left arm is moved. How should the nurse document this finding using the AVPU scale?
1) A
2) P
3) U
4) V

Question 32

A patient with traumatic injuries to the abdomen expresses the fear of dying. What can the nurse do to provide comfort to the patient at this time? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Face the patient when talking.
2) State phrases that demonstrate care and comfort.
3) Hold the patient's hand.
4) Provide pain medication.
5) Leave the patient to rest.

Question 33

A patient with traumatic injuries has a carotid pulse of 64 bpm. What should this finding indicate to the nurse?
1) The patient is not actively bleeding.
2) The injuries are not as severe as they seem.
3) Blood pressure is at least 60 to 80 mm Hg systolic.
4) Blood pressure is at least 40 to 60 mm Hg diastolic.

Question 34

A patient sustained a thoracic injury from a motor vehicle crash. What finding suggests that the patient is developing cardiac tamponade? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Dropping blood pressure
2) Jugular vein distention
3) Muffled heart sounds
4) Drop in blood pressure on inspiration
5) Increase in blood pressure on inspiration

Question 35

The nurse prepares to complete the secondary survey of a patient admitted with a traumatic chest injury. On what should the nurse focus when conducting this survey? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Full set of vital signs
2) Comfort measures
3) Head-to-toe assessment
4) Assessment of posterior surfaces
5) Exposure

Question 36

The nurse assesses a patient with abdominal injuries sustained during a motor vehicle crash. Which finding indicates that the patient may have bleeding from the liver? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Hematuria
2) Left shoulder pain
3) Absent bowel sounds
4) Tender costovertebral angle
5) Bruising around the umbilicus

Question 37

Under the F section of the assessment process, in addition to full vital signs, the family is considered as a part of the treatment process. Which approach to the family would be most appropriate for the nurse to use?
1) The family gets in the way of acute care management, so the nurse should offer no support until the patient is stable.
2) Ethically the family has a right to support the patient by being at the bedside during acute care management, including trauma resuscitation.
3) Depending on the family's awareness of health care management, they have the privilege to watch the care if they do not get in the way of the care.
4) Because the care during trauma management can be too graphic for family to witness, the family should not be allowed at the bedside.

Question 38

What should the nurse do to convey comfort to a trauma patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Explain and talk to the patient, and do not ignore the patient.
2) Give clear, precise directions to follow.
3) Directly look at the eyes of the patient when talking.
4) Provide human contact, such as a reassuring touch.
5) Give all details to get full cooperation.

Question 39

The nurse plans interventions for a patient with traumatic injuries to prevent the onset of the lethal triad. What should the nurse include in this patient's plan of care Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Monitor temperature.
2) Measure intake and output.
3) Evaluate laboratory data.
4) Assess arterial blood gas values.
5) Measure gastric pH.