Question 1

The nurse always treats multiple trauma victims as if a spine injury exists. Which assessment findings would the nurse evaluate as increasing the risk for the presence of a cervical spine injury? Select all that apply.

Accepted Answer

Confusion, lethargy, inability to follow commands, severe facial bruising and trauma, and an obvious depressed skull fracture are all potential signs of cervical spine injury. Severe open abdominal wounds, however, are not typically associated with a risk for cervical spine injury.

Question 2

A woman who is 14 weeks pregnant presents to the ED after falling down a flight of stairs. What should be the nurse's first intervention?

Accepted Answer

The answer of A woman who is 14 weeks pregnant...

Question 3

The mechanism of a patient's injury suggests that the patient may have suffered a basilar skull fracture. The nurse would assess for which findings?Select all that apply.

Accepted Answer

Battle's sign and raccoon eyes are both classic physical assessment findings associated with basal skull fractures. Hyphema is associated with eye injuries and not specifically with basal skull fractures. Rigid extension of the forearms may be a sign of a more severe head injury, but it is not specific to basal skull fractures. Anasarca refers to widespread swelling and is not directly related to basal skull fractures.

Question 4

A patient is admitted to the ED with massive trauma. What nursing intervention will help protect this patient from coagulopathy?

Accepted Answer

Covering the patient with a blanket helps maintain body temperature, which is crucial in preventing hypothermia-induced coagulopathy in trauma patients.

Question 5

During the secondary survey it is discovered that a trauma patient has pelvic instability. Which nursing actions are indicated? Select all that apply.

Accepted Answer

Monitoring for bleeding is crucial as pelvic instability can lead to significant internal bleeding. Assisting with wrapping a sheet around the pelvis helps stabilize the pelvis and reduce movement, which can prevent further injury and bleeding.

Question 6

During the resuscitation of a patient with severe multiple trauma, an order for placement of an indwelling urinary catheter is given. The nurse would that order in the presence of which assessment findings?Select all that apply.

Accepted Answer

Placement of an indwelling urinary catheter in a patient with severe multiple trauma should only be done after a thorough assessment for any potential contraindications. Blood at the urethral meatus indicates possible urethral injury and placement of a catheter may cause further damage. Bruising across the perineum may also indicate pelvic or urethral injury and catheterization should be avoided. Distention of the abdomen and elevated BUN levels are not direct contraindications for urinary catheterization. Hyphema refers to bleeding within the eye and is not related to urinary catheterization.

Question 7

Which assessment finding would the nurse evaluate as a possible indication that an older adult is being abused?

Accepted Answer

Injuries in various states of healing over the patient's trunk and extremities may indicate physical abuse.

Question 8

Which assessment findings would the nurse evaluate as supporting the diagnosis of flail chest?Select all that apply.

Accepted Answer

Flail chest is characterized by paradoxical chest movement, where an area of the chest wall moves inward during inspiration (A). It often results in pain and difficulty breathing, leading to a weak, painful cough (B) and shallow respirations (D). A sucking chest wound (E) is more indicative of an open pneumothorax, not flail chest. A broken rib (C) alone does not confirm flail chest, which involves multiple rib fractures.

Question 9

A patient drove himself to the ED after falling from the roof of his one-story home. The nurse assesses the patient, considering that the fall was probably from about _____ feet.

Accepted Answer

The answer of A patient drove himself to the ED...

Question 10

A patient was hospitalized 36 hours ago after suffering multiple injuries, including flail chest on the right, in an explosion. This morning the patient has moist crackles in the right lung, and the sputum is streaked with blood. The nurse discusses these findings with the health care provider due to concern about the possibility of which injury?

Accepted Answer

The patient's symptoms of moist crackles in the right lung and sputum streaked with blood are indicative of a pulmonary contusion, which is a common injury associated with blunt chest trauma such as that experienced in an explosion. Tension pneumothorax would present with a sudden onset of shortness of breath and tracheal deviation, hemothorax would present with decreased breath sounds and dullness to percussion on the affected side, and pneumonia would present with fever, productive cough, and chest pain.

Question 11

The nurse providing care to a patient with multiple trauma is suspicious that intimate partner violence (IPV) may be the source of the injury. Which findings would increase the nurse's concern?Select all that apply.

Accepted Answer

Frequent visits to the emergency department for injuries (A), a partner who refuses to leave the room (B), the patient attributing injuries to their own clumsiness (D), and inconsistencies between the injuries and the history provided (E) are all red flags for intimate partner violence (IPV). These signs suggest that the injuries may not be accidental and that the patient may be in a controlling or abusive relationship.

Question 12

The emergency services department of a hospital has adopted a policy of tertiary survey for all admitted trauma patients. The nurse understands that this survey will be done within ______ hours of admission.

Accepted Answer

The answer of The emergency services department of a hospital...

Question 13

A patient was brought to the ED after falling from a tree. The patient has an open femur fracture and is bleeding from several lacerations across the abdomen and chest. The patient cannot remember what happened, the skin is cool and pale, and the femoral pulses are weak. Which nursing interventions are necessary? Select all that apply.

Accepted Answer

A) Notify the health care provider immediately because the patient is critically ill and needs emergency medical attention. 
B) Start two large-bore IV lines to administer fluids and potentially blood products. 
C) Apply pressure to bleeding wounds to control bleeding and prevent further blood loss. 
D) Applying a splint to the injured leg can wait until after more urgent interventions are completed. 
E) Place the patient on oxygen to help improve oxygenation and perfusion.

Question 14

A 28-year-old woman is admitted to the ED with trauma sustained when a building collapsed. The nurse would why which test was not ordered?

Accepted Answer

Pregnancy test is not typically ordered for trauma patients unless there is a specific reason to suspect pregnancy.

Question 15

A patient who sustained massive trauma has just lost consciousness. A cardiac monitor is initiated, and it reveals pulseless electrical activity. The team working on this patient would quickly assess for which conditions?Select all that apply.

Accepted Answer

Pulseless electrical activity (PEA) indicates the presence of organized electrical activity in the heart, but there is no detectable pulse or blood pressure. The management of PEA includes identification and correction of the underlying cause. The conditions that the team would assess for in this scenario include cardiac tamponade, tension pneumothorax, and profound hypovolemia. Loose electrical leads to the monitor and spinal cord injury are not likely to cause PEA.

Quiz 67: Caring for the Patient With Multisystem Trauma