Deck 28: Trauma Surgery

Question 1

Mechanism of injury (MOI),or kinematics,involves the action of forces on the human body and their effects.Motor vehicle collisions (MVCs)account for a high degree of blunt trauma.In the case of an adult trauma victim who is the driver in a head-on MVC at high speed,where the head hits the windshield and the chest impacts the steering wheel,what is the MOI and description of the possible injuries?

A) Acceleration; contusion of the occipital lobe of the brain and posterior chest wall
B) Deceleration; contusion of the frontal lobe of the brain and anterior chest wall
C) Acceleration/deceleration; injury to the anterior and posterior brain and internal thoracic organs and vessels
D) Blunt force trauma; impact force causes subdural and epidural hemorrhage and transaction of the thoracic aorta and great vessels

Answer 1

C
During an MVC,three collisions occur.The first collision is that of a car into another object.The second collision is the impact of the occupant's body on the vehicle's interior.The third collision occurs when an internal body structure hits a rigid bony surface.A coup-contrecoup injury of the brain,for example,is the result of an acceleration force to one area of the brain and a deceleration force to an opposite area.The blunt trauma injury results from a combination of forces,such as acceleration and deceleration,and may not result in a break of the skin.

Question 2

The extent of injury after blunt trauma may be difficult to determine.What noninvasive diagnostic test is critical to diagnosis in potential traumatic brain injury?

A) Pupil reflex and response to light
B) Skull radiograph
C) CT scan of the head
D) Neurovascular arteriography

Answer 2

C
If the resources are available,the trauma center (TC)protocol may also include a CT scan as a diagnostic or screening tool.Depending on the MOI,such as a fall,CT scans of the head and abdomen may be performed.Because injuries in blunt trauma are very difficult to diagnose,the CT scan is frequently done before patient transfer to the OR.A high index of suspicion is maintained for other injuries until proven otherwise.Bowel injuries may be missed during initial scanning.A CT scan of the brain revealing an injury incompatible with life may alter the course of definitive treatment for a patient.

Question 3

Trauma to the chest area is the primary cause of death in approximately 20% to 25% of trauma victims.Involvement of the heart,great vessels,lungs,and diaphragm,attributable to penetrating or blunt injury,can provide multiple unexpected findings when the chest is opened.Because of the nature of the potential findings and expected surgical intervention,what would be an appropriate preparatory nursing action?

A) Set up the autotransfusion system and resuscitation equipment.
B) Prepare the rapid response team and chaplain to be on alert.
C) Call for the small fragment set for rib fracture fixation at closure.
D) Prep the patient from the xiphoid to midthigh.

Answer 3

A
Autologous blood salvage units should also be considered during patient care preparation because blood salvage will be done if not contraindicated by the nature of the injury.Because of the unexpected nature of trauma,planning perioperative care is of the utmost importance.Equipment,instruments,and supplies that have a high probability of use must be immediately available.When the trauma patient is transferred to the OR,the extent of injury is not always known.

Question 4

An adult man was the victim of a low-velocity,low-caliber gunshot wound to the anterior left quadrant of the lower abdomen.The gun was shot at far range.What is the trajectory of the gunshot?

A) Small entrance wound with blast injury to the left sigmoid colon and large exit wound
B) Large entrance wound with complete transection of the left colon and no exit wound
C) Large entrance wound with possible injury to left quadrant vessels and contusion of anterior sigmoid colon
D) Small entrance wound with no exit wound; energy is dissipated to the tissues

Question 5

Which statement regarding level III and level IV TCs best describes the difference between the two types of centers?

A) A level III TC provides advanced cardiac life support (ACLS), surgery, stabilization, and transfer, while a level IV only provides ACLS services before immediate transfer to a higher level center.
B) A level III TC immediately transfers to a higher level center, while a level IV does not accept trauma patients.
C) A level III TC determines severity of injury and provides ACLS support before transfer to a level IV center, while a level IV provides all comprehensive services.
D) A level III TC provides all types of trauma services but is in a rural setting, while a level IV provides post-hospital convalescent care for trauma patients.

Question 6

Mandibular fractures are highly associated with assault as the MOI.The goals of operative intervention are to reduce and immobilize the fracture,prevent infection,and restore facial cosmesis and function.What might be an appropriate nursing action and a nursing outcome statement for a patient with a mandibular fracture caused by assault?

A) Manage uncontrolled bleeding; the patient will have effective circulating volume.
B) Provide support and explain interventions; the patient will have fear-related behaviors.
C) Provide caring behaviors and offer comfort to allay fear and anxiety; the patient will experience relief of pain.
D) Facilitate the family's presence; the patient and family will experience decreasing anxiety and fear.

Question 7

What special consideration should be made when assessing geriatric trauma patients before surgery?

A) They may have preexisting diseases and conditions.
B) They commonly have diminished mental capacity and will have difficulty understanding the information provided.
C) They have increased physiologic reserves.
D) The Glascow Coma Scale cannot be applied if the patient has dementia.

Question 8

Which statement regarding level I and level II trauma centers (TCs)best describes the difference between the two types of centers?

A) A level I TC is staffed 24 hours/7 days, while a level II has many support services that are open and staffed 8 hours/5 days.
B) A level I TC has a transplant program, while a level II is only able to complete organ procurements.
C) A level I TC provides care for every type of injury, while a level II lacks some specialized resources.
D) A level I TC requires trauma certification and 8 hours of annual trauma education for all staff, while a level II does not.

Question 9

What is the description of damage control surgery,and what conditions may be present?

A) Trauma surgery performed by a nontrauma surgeon; lack of specialty training
B) Surgery performed during ambulance or helicopter transfer; patient movement
C) Surgery that puts emphasis on trauma impact instead of complete anatomy repair; intentional retained sponges
D) Surgery performed in the ED; inadequate sterile technique

Question 10

Focused assessment with sonography in trauma (FAST)may assist with diagnosis in difficult situations.Which group of scans is performed,and what do they identify?

A) Chest, pelvic, and four abdominal scans; collections of fluid and free air
B) Chest, abdominal, and cervical spine scans; hemorrhage
C) A full body scan; midline shifts
D) Upper and lower extremity scans; compartment syndrome

Question 11

A 7-year-old girl fell from a swing at school and landed on her head.She is not conscious.On the baseline neurologic exam,her Glascow Coma Scale (GCS)is 5.What is the recommended immediate treatment of choice?

A) Reassess with the modified GCS for children.
B) Phenytoin 15 to 20 mg/kg IV.
C) Monitor for hypotension and drug interactions.
D) Intubate with controlled ventilation.

Question 12

The perioperative nurse may not be able to assess the trauma patient until the patient arrives in the OR for surgical intervention.If the patient's condition permits,the perioperative nurse should obtain a brief,precise report from the ED nurse.One component of this report is the SAMPLE history.What are the components of the SAMPLE mnemonic?

A) SPO₂, assessment, MOI, pulse, level of consciousness, electrolytes
B) Social history, available family, medical history, problem, language, environmental conditions of event
C) Symptoms, allergies, medications, past medical history, last oral intake, event leading to injury
D) Special considerations, additional diseases, mean arterial pressure, prior surgeries, labs, extraneous injuries

Question 13

A trauma patient is rushed to the OR after a primary survey is completed in the ED.He is a 36-year-old man with multiple penetrating gunshot wounds to the abdomen.He is bleeding profusely.What appropriate nursing actions are critical in the rapid preparation for this procedure?

A) Set up the autotransfusion system.
B) Prep the patient from the suprasternal notch to the midthigh.
C) Place the aortic cross-clamp on the Mayo stand.
D) Open a silo-bag closure system on the sterile field.

Question 14

With injury to the brain,swelling may occur quickly,requiring aggressive decisions to manage increasing ICP.What is an appropriate diuretic medication to give,and what nursing actions would be indicated for an older adult patient with traumatic brain injury,increased ICP,and a history of congestive heart failure (CHF)?

A) Mannitol 1.5/kg IV; monitor cardiovascular status
B) Furosemide 20 to 40 mg IV; monitor for hypotension and note extent of diuresis
C) Mannitol 1.5/kg IV; monitor cardiovascular status; and furosemide 20 to 80 mg IV; monitor for hypotension and note extent of diuresis
D) Neither mannitol 1.5/kg IV; monitor cardiovascular status; nor furosemide 20 to 80 mg IV; monitor for hypotension and note extent of diuresis

Question 15

A 26-year-old woman is rushed to the OR after a primary and secondary survey in the ED.She was hit by a small truck as she was riding her bicycle through a busy intersection.She has sustained rib fractures and several fractured transverse vertebral processes.Renal injury is suspected.As the perioperative nurse prepares to insert a urinary catheter,she notices blood at the urinary meatus.What should the nurse's next action be?

A) Place a gauze dressing over the perineum after inserting the urinary catheter.
B) Insert the catheter and notify the surgeon.
C) Discontinue the catheter insertion.
D) Insert a latex-free straight catheter to empty the bladder and then remove it.

Question 16

Trauma patients often arrive with cervical collars in place,or collars are placed by the ED team if cervical spine injury is suspected.What event needs to take place before the team removes the cervical collar and continues care?

A) A halo traction apparatus is applied.
B) A cervical radiograph is obtained to rule out injury to the neck.
C) A computed tomography (CT) scan with contrast of the upper body is obtained to rule out vascular involvement.
D) A myelogram of the cervical spinal canal is obtained to rule out injury to the spinal cord.

Question 17

If an injury to a patient is a result of a violent crime,the team must give special attention to preservation of evidence during patient care.When clothing is removed from the patient,why must it be placed and secured in a paper bag rather than a plastic bag?

A) Plastic bags may trap moisture and allow mold growth, destroying evidence.
B) It is easier to write identifying information on paper rather than plastic.
C) Plastic bags trap air, which could kill anaerobic microorganisms needed as evidence.
D) Paper bags are more secure as they cannot be untied and retied.

Question 18

Blunt force to the larynx can result in a fracture and impose immediate airway obstruction.These patients are at risk for a lost airway and may require immediate tracheotomy followed by repair of the fracture when the fracture is unstable or displaced.It is also important to consider that a trauma patient is assumed to have a full stomach; thus,these patients are at high risk for aspiration and resultant pneumonia.What is an appropriate nursing action in the event of a lost airway after anesthesia induction and before intubation?

A) Assist the anesthesia provider with securing the airway while applying cricoid pressure.
B) Assist the anesthesia provider by inserting a nasogastric tube and connecting to suction.
C) Obtain emergency tracheostomy tray and trach tubes.
D) Increase the oxygen delivery and perform a head tilt-chin lift.

Question 19

When the patient arrives in the emergency department (ED),the trauma team initiates a primary assessment.This is a logical,orderly process of patient assessment for potential life threats.These assessment activities are based on established protocols for advanced trauma life support (ATLS).The mnemonic "ABCDE" is used,representing assessment of the following: airway,breathing,circulation,disability,and exposure.The D and E represent what degree of investigation?

A) D = musculoskeletal impairments; E = environmental issues
B) D = a brief reflex examination; E = extraneous sensory impairments
C) D = history of prior impairments; E = events that contributed to the injury
D) D = a brief neurologic examination; E = exposure to reveal all life-threatening injuries

Question 20

Traumatic deaths may occur in three phases or time frames.Which phase occurs within the first 1 to 2 hours after the injury,where definitive trauma care has the most significant effect?

A) Phase I
B) Phase II
C) Phase III
D) Phase IV

Question 21

Autotransfusion can present a vital asset in trauma care when considering the high blood loss associated with many traumatic injuries.This process provides immediate volume replacement,decreases the amount of bank blood used,and reduces the possibility of transfusion reactions or risk of transfusion with bloodborne pathogens.What are the contraindications to using autotransfusion as a blood replacement source?

A) Clean, hemodiluted blood
B) Blood contaminated with food, bowel contents, or antibiotic irrigation
C) Blood and fluids squeezed out of sterile bloody sponges
D) Pooled blood from a torn aorta

Question 22

Traumatic injury is the most common indication for nonobstetric surgery during pregnancy.The normal physiologic changes that occur during pregnancy increase the challenge of evaluation and treatment when pregnant women are victims of trauma.Select the statements which best describe considerations in perioperative assessment of the pregnant trauma patient.

A) Plasma volume increases by 50%, creating an increased susceptibility to blood loss.
B) Blood pressure falls in the second trimester which may be misinterpreted as hypovolemia.
C) Gastric emptying is slowed, increasing the risk of aspiration.
D) The bladder is displaced in second and third trimesters increasing the risk of bladder injury in abdominal trauma.
E) Coagulation factors are increased, amplifying the risk of DVT.

Question 23

The emergency medical services system consists of trained prehospital personnel who arrive at the scene and perform definitive interventions designed to reduce morbidity and mortality.What is the primary role of the prehospital personnel?

A) Scoop and run to the nearest hospital ED while performing ABCs.
B) Deliver the victim to the hospital before the end of the golden hour.
C) Determine the severity of injury and initiate medical treatment.
D) Identify the most appropriate facility to which to transport the victim.