Question 1

What should the nurse expect to assess in a patient with a tension pneumothorax?

Accepted Answer

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?

Accepted Answer

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.

Accepted Answer

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.

Accepted Answer

1. Jugular vein distention will increase when chest pressure rises with displacement or fluid buildup in which the heart must work harder to circulate the blood and perfuse tissues that are hypoxic.
2. Chest movement symmetry will be assessed in the patient with thoracic trauma.
3. Chest movements that rise and fall with breathing will be assessed in the patient with thoracic trauma.
4. Respiratory rate, pattern, and effort will be assessed in the patient with thoracic trauma.
5. Skin coloring is a circulation issue, not a breathing issue.

Question 5

Which complication should the nurse plan care for a patient recovering from a pulmonary contusion?

Accepted Answer

1. The nurse should focus on preventing the development of pneumonia, which is the most common complication resulting from a pulmonary contusion post-chest wall injury.
2. Tension pneumothorax is not a complication of a pulmonary contusion.
3. Flail chest is not a complication of a pulmonary contusion.
4. Pulmonary edema is not a complication of a pulmonary contusion.

Question 6

Which goals are appropriate for a patient with a traumatic injury and an ineffective breathing pattern? Select all that apply.

Accepted Answer

1. This will maximize available oxygen and allow the least respiratory effort to increase perfusion to the greatest number of alveolar areas.
2. This will maximize available oxygen and allow the least respiratory effort to increase perfusion to the greatest number of alveolar areas.
3. Although remaining calm will decrease the oxygen demand, this is not likely to occur when breathing difficulties create both physical and emotional stress. Sedation may be needed if ventilation is in use and the patient is fighting the ventilator.
4. Preventing infection will allow the least respiratory effort to increase perfusion in the greatest number of alveolar areas.
5. Although keeping the lung tissue moist is the ideal way to improve cellular tissue exchange, it will not help if the problem is ineffective breathing. The muscle effort or surface available to exchange is the problem that needs correction.

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?

Accepted Answer

1. This is a true statement and does not need additional teaching.
2. Septic shock is not more common than hemorrhagic shock. Hemorrhage is the most common cause for shock.
3. This is a true statement and does not need additional teaching.
4. This is a true statement and does not need additional teaching.

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?

Accepted Answer

1. Hyperventilating the patient lowers the ICP by lowering the PaCO₂ that is causing vasoconstriction of the cerebral blood vessels and reducing cerebral blood flow. 2. This position places the patient at greater risk of permanent damage from decreased cerebral blood flow. 3. Emergency surgery might be needed, but hyperventilating the patient will temporarily allow more time for informed decision making. 4. Although this may be a life and death event, the activity that might reduce this risk can be temporarily avoided by hyperventilation first.

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.

Accepted Answer

1. The chest wall injury would be a breathing survey assessment because it focuses on thoracic trauma and the ability to ventilate and not obstruct the airway itself.
2. This can obstruct the airflow into or out of the lungs and cause airway failure.
3. This can obstruct the airflow into or out of the lungs and cause airway failure.
4. This can obstruct the airflow into or out of the lungs and cause airway failure.
5. This can obstruct the airflow into or out of the lungs and cause airway failure.

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?

Accepted Answer

1. This action would be seen in step B-Breathing.
2. This action would be seen in step E-Environment/exposure.
3. Airway is covered under the A section. Maintaining an open airway is the first priority. With a fracture or trauma to the neck, respirations may be altered or prevented by bone or tissue misalignment. The jaw thrust maneuver is the correct way to open the airway for a cervical spine injury.
4. This action is performed in step H-Head-to-toe assessment/medical history.

Question 11

Which interventions should the nurse implement for a patient with a sucking chest wound? Select all that apply.

Accepted Answer

1. Pain medication will allow an ease in the breathing effort and reduce pain on insertion of the chest tube.
2. The nurse will continuously monitor pulse oximetry and respiratory characteristics.
3. Emergency intubation may not be required because the patient can still breathe. The problem is not the effort to inhale or exhale air but to expand the collapsed lung tissue and prevent pressure buildup in the enclosed lung cavity.
4. Chest tubes are used to reinflate lung tissue by creating a negative pressure.
5. A sucking chest wound sucks atmospheric air into the chest cavity with each breath. Closing off this air will decrease the collapse of lung tissue by using a dressing that allows air to leave the chest cavity (thus not taping all four sides) but decreasing the intake of air on inhalation.

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?

Accepted Answer

1. Internal forces refer to stress or strain created within the body, not from outside forces. Acceleration forces are when the increasing speed hits someone who is stationary, such as a car hitting a person crossing the street.
2. Blunt trauma leaves the skin intact and damages underlying tissue, such as broken ribs. External forces are created by the mass of the object and velocity of movement outside the body and the weight of the person being pushed forward after the car hit something. Deceleration is the force that stops or decreases the velocity of the moving victim, such as the chest hitting the steering wheel.
3. Penetrating wounds have an open wound, and flail chests are intact at the skin level.
4. Penetrating wounds have an open wound, and flail chests are intact at the skin level. Internal forces refer to stress or strain created within the body, not from outside forces.

Question 13

A patient is being treated for cardiac tamponade. What should the nurse consider as a reason for the health problem to recur?

Accepted Answer

1. Unless immediate treatment is initiated, the tamponade will reoccur.
2. Cardiac tamponade is not caused by hypertension.
3. This is a treatment to repair cardiac tamponade.
4. This is a treatment to repair cardiac tamponade.

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.

Accepted Answer

1. This is assessed under the disability part of the primary assessment.
2. Vital signs are classified under F-Full set of vital signs.
3. This is assessed under the disability part of the primary assessment.
4. This is assessed under the disability part of the primary assessment.
5. Oxygen levels are covered under C-Circulation of the primary assessment steps.

Question 15

Which nursing assessment should have highest priority for early airway management of a trauma patient?

Accepted Answer

1. If the patient can state his or her name audibly, the airway is patent.
2. ICP monitoring might be needed, but it is not the first priority of the nurse for airway issues.
3. Emergency tracheostomy might be needed, but it is still a second action only if needed.
4. CT scanning might be needed, but it is not the first priority of the nurse for airway issues.

Question 16

Which assessment finding indicates that a patient with a traumatic injury is having problems with breathing rather than difficulty maintaining an airway?

Accepted Answer

1. Each of these symptoms is an example of an airway maintenance issue that can contribute to decreased airflow through the throat.
2. Chest pain is a breathing issue and not an airway problem.
3. Crepitus is noted with laryngeal fractures where air is escaping into the subcutaneous tissue.
4. This is an example of an airway maintenance issue that can contribute to decreased airflow through the throat.

Question 17

Which goal should receive the highest priority when caring for the patient with a cervical spine injury?

Accepted Answer

1. Pain relief is not of the highest priority at this time.
2. Cervical alignment is not of the highest priority at this time.
3. Due to the risk of airway obstruction and damage to nerves that stimulate respiratory function, ventilation may need to be controlled or assisted. Maintaining oxygenation is the priority at this time.
4. Promoting hypothermia is not of the highest priority at this time.

Question 18

During the assessment of a patient with a suspected cardiac tamponade, for what should the nurse monitor? Select all that apply.

Accepted Answer

1. This is a symptom of cardiac tamponade.
2. This is a symptom of cardiac tamponade.
3. This is a symptom of cardiac tamponade.
4. Jugular vein distention would increase, not decrease, with the increasing backup of blood and the decreasing contractility from the limited motion of the ventricles as fluid/blood builds up within the sac, limiting its ability to move.
5. Bounding peripheral pulses would not occur in the patient with cardiac tamponade.

Question 19

When managing shock, which statement is incorrect when comparing the level or classification of shock to the drug treatment?

Accepted Answer

1. Class I-treated with colloid fluid resuscitation is incorrect and should be treated with isotonic fluids.
2. This is the correct treatment for Class II shock.
3. This is the correct treatment for Class III shock.
4. This is the correct treatment for Class IV shock.

Question 20

Which patient assessment data supports an open traumatic injury?

Accepted Answer

1. This is an example of blunt trauma in which the skin is not broken but underlying tissue is damaged.
2. This is an example of blunt trauma in which the skin is not broken but underlying tissue is damaged.
3. This is an example of blunt trauma in which the skin is not broken but underlying tissue is damaged.
4. Burns over 30% of the body from a house fire is an example of an open or penetrating wound in which the skin does not remain intact.

Quiz 9: Care of the Patient Following Traumatic Injury