Deck 11: Nursing Care of Patients Experiencing Trauma and Shock

Question 1

A patient is brought to the emergency department with injuries sustained when a wall collapsed in the home. The nurse recognizes that this patient's injuries were most likely caused by which mechanism of injury?

A) crushing
B) shearing
C) deceleration
D) blast

Answer 1

crushing

Question 2

A patient was admitted with a head injury caused by rapid acceleration and deceleration. How should the nurse expect this patient's injuries to be classified?

A) blunt
B) shearing
C) blast
D) minor

Answer 2

blunt

Question 3

A patient is brought to the emergency department with a penetrating wound to the neck. The patient is dyspneic and cyanotic and has evidence of subcutaneous emphysema. What does the nurse expect the physician to do initially?

A) intubate the patient because of the severe wound
B) notify the next of kin regarding the patient's condition
C) order x-rays of the lumbar area to assess for fractures
D) administer a beta blocker to alleviate the sympathetic response

Answer 3

intubate the patient because of the severe wound

Question 4

A patient with multiple traumatic injuries has experienced severe blood loss and is prescribed to receive blood immediately. The nurse realizes that because there is not enough time for type and crossmatch, the patient will most likely receive which type of blood?

A) O
B) A
C) B
D) AB

Question 5

A patient is brought to the emergency department with injuries sustained in a motor vehicle crash. What should the nurse consider as the cause of this patient's injuries?

A) trauma
B) not wearing a seat restraint
C) a drunk driver
D) not paying attention while driving

Question 6

A patient is brought to the emergency department with physical injuries sustained in a gang fight. The patient's blood pressure is 80/50 mmHg, with a pulse of 120 and thready. Which diagnostic test should the nurse expect to be performed to provide the fastest information?

A) sonogram
B) complete blood count
C) urinalysis
D) serum electrolyte levels

Question 7

A patient is admitted to the hospital with injuries from a motor vehicle crash. During the nurse's initial assessment, the patient develops hypotension and severe jugular distension with a tracheal deviation. What should the nurse suspect is occurring in this patient?

A) tension pneumothorax
B) hemorrhage
C) compensatory shock
D) hypovolemic shock

Question 8

A patient recovering from a motor vehicle accident tells the nurse that the other car "barely" hit him and asks why he has so many injuries. How should the nurse respond?

A) "The car that hit you transferred a large amount of energy to your body, causing these injuries."
B) "You have other health problems that make the injuries worse."
C) "The driver of the other car intended to hit you."
D) "Because you are older, your injuries will be worse."

Question 9

A construction worker was admitted after falling from the roof of a building. The nurse should plan care for this patient's injuries based on which energy source?

A) gravitational
B) mechanical
C) physical
D) electrical

Question 10

The nurse suspects that a patient who was in a motor vehicle crash does not have a cervical spine injury. What did the nurse assess to come to this conclusion?

A) alert without midline cervical tenderness
B) lacking motor response in lower extremities
C) lacking deep tendon reflexes
D) lethargic and confused

Question 11

The nurse determines that a patient is experiencing ongoing progression of a shock state. What finding led the nurse to come to this conclusion?

A) decrease in serum glucose level
B) drop in blood urea nitrogen level
C) increased eosinophil level
D) low serum cardiac enzyme level

Question 12

A pediatric patient is admitted after ingesting a household cleaning solution. The nurse should plan care for this patient's injuries based on which energy source?

A) chemical
B) physical
C) thermal
D) mechanical

Question 13

A patient comes into the emergency department with leg pain after falling on ice. For which classification of injuries should the nurse expect to plan care for this patient?

A) Class 3 minor
B) Class 1 minor
C) Class 1 penetrating
D) Class 3 penetrating

Question 14

A patient is admitted with possible head and spinal cord injuries sustained after falling from a ladder. Which diagnostic test should the nurse expect to be prescribed that will identify the type and extent of this patient's injuries?

A) magnetic resonance imaging
B) cervical spine x-rays
C) spinal cord x-rays
D) cerebral angiogram

Question 15

A patient is admitted with a diagnosis of blunt trauma to the abdomen after a motor vehicle crash. What should the nurse assess first when the patient arrives in the emergency department?

A) airway for patency
B) abdomen for any abnormalities
C) cervical spine for tenderness
D) signs of neurological deficits

Question 16

A patient with multiple gunshot wounds to the abdomen has received 8 units of blood. The blood bank notifies the nurse that they have run out of blood for the patient. The nurse knows the patient can receive any type of blood if the patient has which blood type?

A) AB
B) A
C) B
D) O

Question 17

An older patient is admitted after falling on the steps at home. Which components of trauma should the nurse consider when planning care for the patient?

A) host
B) environment
C) intention
D) source
E) transmission

Question 18

The spouse of a patient admitted with a gunshot wound asks the nurse when her husband will be discharged so that they can resume their life together. How should the nurse respond?

A) "Right now there is no way of knowing how soon your husband can return to his previous life."
B) "I would say in a few weeks."
C) "Probably never."
D) "As soon as the wound heals, your husband can return to work."

Question 19

A victim of a multivehicle automobile crash is brought into the emergency department. The patient has slurred speech and is lethargic. The nurse anticipates that which diagnostic tests would be indicated for this patient?

A) blood alcohol level
B) urine drug screen
C) skull x-rays
D) chest x-ray
E) urinalysis

Question 20

A patient is admitted with a thermal injury. Which mechanism of injury should the nurse consider as the most likely cause of this patient's injuries?

A) fire
B) lightning
C) ultraviolet radiation
D) gunshot

Question 21

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?

A) Remove the patient's clothing and place in a breathable bag.
B) Cover the patient's hands with plastic bags.
C) Cut off the patient's clothing and bathe the skin and wounds as soon as possible.
D) Place clothing and other patient items on a bedside table and have a nursing assistant remove them when possible.

Question 22

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?

A) failure of sodium-potassium pump
B) cells shrinking
C) full and bounding peripheral pulses
D) metabolic alkalosis

Question 23

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?

A) jugular vein distention
B) warm extremities
C) laryngospasm
D) urticaria

Question 24

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?

A) Ringer's lactate
B) Dextrose 5% and water
C) Dextrose 5% and 0.45% normal saline
D) Dextrose 5% and 0.9% normal saline

Question 25

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?

A) Mean arterial pressure reaches 60.
B) Mean arterial pressure reaches 90.
C) Blood pressure reaches 120/80 mmHg.
D) Urine output is 10 mL per hour.

Question 26

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?

A) The patient described severe nightmares related to the event.
B) The patient denied anger or shock.
C) The patient denied the need for drug or alcohol counseling.
D) The patient stated that her family is very supportive.

Question 27

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

A) Maintain systolic blood pressure of 90 mmHg.
B) Keep oxygen saturation level at 75%.
C) Administer intravenous fluids to maintain a urine output of 25 mL per hour.
D) Perform external cardiac compressions to achieve a heart rate of 60 beats per minute.

Question 28

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

A) absence of gag or corneal reflex
B) absence of oculovestibular reflex
C) apnea with PaCO₂ of 66 mmHg
D) toxic metabolic disorders
E) response to deep stimuli

Question 29

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?

A) Provide active range-of-motion exercises to affected extremities every 8 hours.
B) Turn and reposition every hour.
C) Remove anti-embolic stockings for 3 hours every shift.
D) Administer tetanus toxoid.

Question 30

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

A) signs of stridor, cough, or respiratory distress
B) blood pressure
C) need for suctioning
D) loose teeth or obvious problems with the mouth

Question 31

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?

A) "With head injuries, the patient can continue to make movements, but these are reflexes that do not reflect brain function."
B) "Your husband will likely recover in time."
C) "As long as he has oxygen to the brain, he will recover."
D) "His movements indicate that his brain is dead."

Question 32

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

A) 25% albumin
B) 0.9% normal saline
C) dextrose 5% and 0.45 % normal saline
D) dextrose 5% and water

Question 33

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

A) Use an infusion pump.
B) Administer with PVC tubing.
C) Use within 8 hours of reconstitution.
D) Allow the patient to get out of bed only with assistance.

Question 34

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?

A) distributive
B) obstructive
C) hypovolemic
D) anaphylactic

Question 35

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

A) slight increase in heart rate
B) nonpalpable peripheral pulses
C) narrowing pulse pressure
D) increase in blood glucose level

Question 36

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?

A) obstructive
B) hypovolemic
C) cardiogenic
D) neurogenic

Question 37

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

A) blood pressure
B) temperature
C) respirations
D) heart rate

Question 38

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

A) increased heart rate
B) reduced heart rate
C) decreased respiratory rate
D) decreased blood pressure

Question 39

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?

A) hypovolemic
B) cardiogenic
C) septic
D) anaphylactic

Question 40

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?

A) reducing stimuli and medicating for pain
B) assessing blood pressure and heart rate
C) monitoring central venous pressure
D) assessing bowel sounds

Question 41

A trauma patient is being assessed with the Champion Revised Scoring System. What assessment data should the nurse use with this scoring system?

A) diastolic blood pressure
B) heart rate
C) Glasgow coma scale
D) systolic blood pressure
E) respiratory rate

Question 42

The nurse is concerned that a patient with traumatic chest injures is developing respiratory distress. What assessment findings led the nurse to come to this conclusion?

A) combative behavior
B) absent breath sounds in left lower lobe
C) pedal and popliteal pulses weak and irregular
D) temperature raised 2 degrees over the last 4 hours
E) oxygen saturation 86% on 40% oxygen face mask

Question 43

An adolescent is experiencing anaphylactic shock after being stung by a swarm of bees. Which medications should the nurse anticipate being provided to this patient?

A) diuretics
B) antibiotics
C) epinephrine
D) beta2-agonist
E) antihistamine

Question 44

The nurse is reviewing data for a patient experiencing shock. Based on these data, the nurse recognizes that the patient is in which stage of shock? $$\begin{array} { | l | l | } \hline \text { Assessments for Shock } & \text { Patient Manifestations } \\\hline \text { Blood loss } & 1950 \mathrm {~mL} \\\hline \text { Percent of blood volume } & 32 \% \\\text { loss } & \\\hline \text { Heart rate } & 136 \\\hline \text { Blood pressure } & 80 / 65 \\\hline \text { Capillary refill } & > 5 \text { seconds } \\\hline \text { Respiratory rate } & 28 \mathrm { per } \text { minute } \\\hline \text { Urine output } ( \mathrm { mL } / \mathrm { h } ) & 12 \mathrm {~mL} / \mathrm { h } \\\hline \text { Mental status } & \text { Confused } \\\hline\end{array}$$

A) compensatory
B) early, reversible
C) progressive
D) refractory

Question 45

A patient comes to the emergency department with bright red blood flowing from the lower right arm. Place an "X" over the artery over which pressure would be applied to control the bleeding.

Question 46

The nurse is reviewing the laboratory results for a patient with trauma. Based on this information, what care should the nurse plan for this patient? $$\begin{array} { | l | l | } \hline \text { Diagnostic Test } & \text { Patient Results } \\\hline \text { WBC } & 10,000 \text { per } \mathrm { mm } ^ { 3 } \\\hline \text { Neutrophils } & 66 \% \\\hline \text { Monocytes } & 3 \% \\\hline \text { Eosinophils } & 3 \% \\\hline \text { Lymphocytes } & 35 \%\\\hline\end{array}$$

A) fluids for distributive shock
B) nothing, because the results are normal
C) contact precautions
D) central venous catheter insertion

Question 47

During shock, the reticuloendothelial Kupffer cells can be destroyed. In which organ should the nurse identify the location of these cells? Place an "X" on the location of these cells.

Question 48

A patient is admitted with trauma to the integumentary system. Which type of skin trauma should the nurse prepare to assess?

A) cutaneous
B) abrasion
C) laceration
D) contusion
E) keloid

Question 49

Emergency personnel are preparing to complete an on-the-scene rapid assessment of a victim of a motor vehicle crash. In which order should the victim's assessment be completed? Place the assessments in order of importance.

A) assessment for obvious injuries
B) Champion Revised Trauma Scoring System
C) airway and breathing assessment
D) circulation assessment
E) level of consciousness and pupillary function
F) non of the above.

Question 50

A patient is to receive nitroglycerin (Tridil) 10 mcg/min. The medication strength is 50 mg/250 mL. The IV rate should be ________________ mL/min.

Question 51

A patient has received 145 mL of blood and complains of chills. For what should the nurse assess this patient?

A) bradypnea
B) urticaria
C) fever
D) hypertension
E) lumbar pain

Question 52

A patient in hypovolemic shock is receiving an intravenous colloid solution (plasma expander). Which assessment findings indicate to the nurse that the infusion rate should be reduced?

A) prothrombin time of 13.5 seconds
B) jugular vein distention
C) tenting of the skin
D) increased central venous pressure
E) auscultation of crackles and wheezes

Question 53

A patient receiving a unit of packed red blood cells for hypovolemic shock is demonstrating signs of a transfusion reaction. In which order should the nurse provide care to this patient?

A) Stop the transfusion and notify the physician
B) Compare the blood slip with the unit of blood
C) Assess vital signs and associated manifestations
D) Save the blood bag and tubing for laboratory analysis
E) Collect urine and venous blood samples according to policy
F) non of the above.

Question 54

A patient with thoracic injuries sustained in a multivehicle crash is demonstrating an alteration in perfusion. What should the nurse do to help this patient?

A) Auscultate lung sounds.
B) Measure blood pressure.
C) Measure central venous pressure.
D) Reduce rate of intravenous fluids.
E) Assess for jugular vein distention.

Question 55

An older patient with an infected stage IV pressure ulcer is lethargic. What additional findings should the nurse expect to assess in this stage of septic shock?

A) warm, flushed skin
B) urine output 10 mL/hr
C) blood pressure 88/54 mmHg
D) heart rate 118 beats per minute
E) respiratory rate 28 per minute and shallow