Deck 11: Nursing Care of Patients Experiencing Trauma and Shock

Question 1

A construction worker was admitted after falling from the roof of a building. The energy source for this patient's injuries was most likely caused by which of the following?

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

Answer 1

gravity

Question 2

A patient is brought to the emergency department with physical injuries sustained from a gang fight. The patient's blood pressure is 80/50 mmHg with a pulse of 120 and thready. The nurse realizes that the diagnostic test that would provide the fastest information to help this patient would be which of the following?

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

Answer 2

sonogram

Question 3

The nurse determines that a patient is having ongoing progression of a shock state when which of the following is assessed?

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

Answer 3

decrease in serum glucose level

Question 4

A patient is admitted with possible head and spinal cord injuries sustained after falling from a ladder. The diagnostic test that will identify the type and extent of injuries for this patient would be which of the following?

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

Question 5

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

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

Question 6

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.

Question 7

A patient is admitted with a thermal injury. The mechanism of injury that this patient most likely experienced would be which of the following?

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

Question 8

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

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

Question 9

A victim of a multi-vehicle automobile accident is brought into the emergency department. The patient has slurred speech and is lethargic. The nurse realizes that which of the following diagnostic tests would be indicated for this patient? Select all that apply.

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

Question 10

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

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

Question 11

A pediatric patient is admitted after ingesting a household cleaning solution. The nurse realizes that the energy source for this patient's injuries would be which of the following?

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

Question 12

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. With which of the following should the nurse respond to this spouse?

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 13

An elderly patient is admitted after falling on the steps at home. Which of the following components does the nurse need to consider when planning care for the patient? Select all that apply.

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

Question 14

The nurse suspects that a patient who was in a motor vehicle accident does not have a cervical spine injury when which of the following is assessed?

A)alert without midline cervical tenderness
B)no motor response of lower extremities
C)lack of deep tendon reflexes
D)lethargic and confused

Question 15

A patient comes into the emergency department with leg pain after falling on ice. The nurse realizes that this patient's injuries would most likely be classified as being which of the following?

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

Question 16

A patient is brought to the emergency department with injuries sustained from a motor vehicle accident. The nurse realizes that this patient's injuries have been caused by which of the following?

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

Question 17

A patient was admitted with a head injury caused by rapid acceleration and deceleration. The nurse realizes that the patient's injuries could also be classified as being which of the following?

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

Question 18

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

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

Question 19

A patient is brought to the emergency department with injuries sustained from a wall that collapsed in the home. The nurse realizes that this patient's injuries are most likely caused by which of the following?

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

Question 20

A patient recovering from a motor vehicle accident asks the nurse why he has so many injuries since the other car "barely" hit him. With which of the following should the nurse respond to the patient?

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

Question 21

A patient, admitted with multiple injuries, is prescribed to receive an intravenous colloid solution. Which one of the following solutions 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 22

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 of the following?

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

Question 23

An adult patient who has died from traumatic injuries is an organ donor. Which of the following 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)Provide intravenous fluids for a urine output to be 25 mL per hour.
D)Provide external cardiac compressions to achieve a heart rate of 60 beats per minute.

Question 24

A patient who was a victim of rape six months ago comes to an outpatient clinic for the treatment of post-traumatic stress disorder. Which data collected during the patient's assessment would indicate a manifestation associated with this disorder?

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

Question 25

Which of the following assessment findings would be seen in a patient who experienced a traumatic brain injury and is being evaluated for brain death? Select all that apply.

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 26

The nurse wants to calculate a patient's mean arterial pressure. Which of the following vital signs would the nurse use to make this calculation?

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

Question 27

The nurse, planning care for a patient diagnosed with shock, would include which of the following interventions for the nursing diagnosis of Anxiety?

A)reduce stimuli and medicate for pain
B)assess blood pressure and heart rate.
C)monitor central venous pressure
D)assess bowel sounds

Question 28

Which of the following interventions would be essential for the nurse to assess first for a patient admitted with severe facial injuries?

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

Question 29

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, which of the following 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 when possible.

Question 30

A patient with traumatic injuries has lost approximately 300 mL of blood. The nurse realizes that which of the following will most likely be assessed in this patient?

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

Question 31

A patient diagnosed with hypovolemic shock is prescribed intravenous fluids while awaiting blood transfusions. The nurse realizes that the solution of choice for this patient would be which of the following?

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 32

The nurse is providing medications to increase a patient's system 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 33

The nurse is preparing to administer intravenous nitroglycerin to a patient diagnosed with cardiogenic shock. Which of the following should the nurse do when providing this medication?

A)Use an infusion pump.
B)Administer with PVC tubing.
C)Use within 8 hours of reconstitution.
D)Patient permitted out of bed with assist only.

Question 34

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

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

Question 35

A patient diagnosed with shock is prescribed dobutamine (Dobutrex). Which of the following would the nurse assess as an effect of this medication?

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

Question 36

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

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

Question 37

The spouse of a patient admitted with severe spinal cord injuries tells the nurse that she believes her husband is going to recover since he continues to make movements that occur without stimulation. Which of the following should the nurse explain to the spouse?

A)"With spinal cord injuries, the patient can continue to make movements which are reflexes but do not reflect brain function."
B)"The patient will most 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 38

A patient hospitalized with traumatic injuries has the nursing diagnosis of Impaired Physical Mobility. Which of the following interventions would be appropriate for this patient?

A)Provide active range of motion exercises to affected extremities once every eight hours.
B)Turn and reposition every one hour.
C)Remove antiembolic stockings for three hours every shift.
D)Administer tetanus toxoid.

Question 39

The nurse suspects that a patient diagnosed with a myocardial infarction is developing cardiogenic shock when which of the following is assessed?

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

Question 40

A patient has an estimated blood loss of two liters and has a mean arterial pressure ranging between 30 and 40 mmHg. If this patient's hemodynamic status is not corrected, the nurse realizes that which of the following can occur?

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

Question 41

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

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

Question 42

A patient has received 145 mL of blood and complains of chills. The nurse will also assess for which of the following? Select all that apply.

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

Question 43

An on-the-scene rapid assessment is completed on the trauma victim. Place the assessments in order of importance. Click and drag the options below to move them up or down.

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

Question 44

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

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

Question 45

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

Question 46

A patient in hypovolemic shock is receiving a colloid solution (plasma expander). The rate of infusion is slowed when the nurse assesses which of the following? Select all that apply.

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

Question 47

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

Question 48

A posttrauma patient has these laboratory results (see above). Based on analyzing of the laboratory results, the nurse 11ea992e_0a7d_e73d_9f38_954c448467a8

A)suspects distributive shock.
B)recognizes the results as normal.
C)places the patient in contact precautions.
D)prepares for insertion of a central venous catheter.

Question 49

During shock, the reticuloendothelial Kupffer cells can be destroyed. Place an "X" on the location of these cells.

Question 50

In reviewing the patient manifestations (see above), the nurse recognizes the patient is in which stage of shock? 11ea992e_0a7d_c02c_9f38_6bd968901aac

A)compensated
B)mild
C)moderate
D)severe