Académique Documents
Professionnel Documents
Culture Documents
3. In addition to lung or heart damage, a stab wound inflicted at or below nipple level
may also cause damage to the:
1. Abdomen.
2. Trachea.
3. Larynx.
4. Urinary bladder.
Correct Answer: Abdomen.
Rationale: During expiration, the dome of the diaphragm reaches as high as the fifth rib.
Stab wounds to the chest at or below the level of the nipple should be inspected for
abdominal injury as well. The trachea, larynx, and bladder would not be within reach of
the typical stab wound instrument.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1
4. If a trauma patient arrives in the emergency department (ED) via ambulance, the
priority nursing assessment would include:
1. Airway management with cervical spine immobilization.
2. Insertion of two large-bore IV catheters.
3. Insertion of Foley catheter.
4. Assessing level of consciousness and ability to follow commands.
Correct Answer: Airway management with cervical spine immobilization.
Rationale: Airway is always priority, with consideration of maintaining the cervical spine
in a midline position. First, the airway is assessed for patency; it may be obstructed by
blood, displacement of tissue, etc.. The other interventions are important as well, but
unless tissues are being oxygenated, death will occur within minutes.
Cognitive Level: Synthesis
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 2
5. For the emergency department client who has external hemorrhage, the most
appropriate way to control the bleeding is for the nurse to:
1. Apply direct manual pressure on the wound.
2. Apply a tourniquet tight enough to stop all the external bleeding.
3. Pack the wound with ice directly on the wound to cause vasoconstriction.
4. Tape ABD pads over the wound and reinforce when they become saturated.
Correct Answer: Apply direct manual pressure on the wound.
Rationale: Direct pressure is the best and easiest way to control external hemorrhage. A
tourniquet can cause crush injury to tissues and distal ischemia. Ice can cause tissue
damage as well. Applying dressings without compression will not control the bleeding.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 2
6. A trauma client who has experienced a blunt cardiac injury from a steering wheel
should be assessed for cardiac tamponade. Which of the following clinical manifestations
would the nurse be assessing for?
1. Neck vein distention, muffled heart sounds, hypotension
2. Jugular vein distention, bounding pulse, harsh murmur
3. Bilateral upper arm distention, hypertension, edema of the face
4. Absent breath sounds on the left, apical pulse displaced to the left, S3 heart
gallop
Correct Answer: Neck vein distention, muffled heart sounds, hypotension
Rationale: Neck vein distention is caused by elevated central venous pressure, muffled
heart sounds is due to the amount of blood surrounding the heart, and hypotension is due
to blood loss (i.e., shock). Bounding pulse is usually seen in hypervolemic states.
Bilateral arm distention is usually caused by pressure placed on the superior vena cava,
which is not related to cardiac tamponade. Murmurs are due to valvular disease. Absent
breath sounds are pulmonary problems. A displaced apical pulse is usually a result of
hypertrophy of the heart. S3 gallop is a classic sign of heart failure.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2
7. The priority NANDA for a hemorrhaging client in the emergency department would
be:
1. Ineffective tissue perfusion related to hypovolemia.
2. Impaired ventilation related to airway obstruction.
3. Fluid-volume deficit related to decreased renal perfusion.
4. Ineffective breathing related to shallow respirations.
Correct Answer: Ineffective tissue perfusion related to hypovolemia.
Rationale: When a client is hemorrhaging, the tissues are not being perfused. Therefore,
major organs such as the heart, brain, and lungs will receive oxygenation, and other
organs such as kidneys, intestines, and long muscles will not receive oxygenation and
will become ischemic. Hemorrhaging relates to arterial and venous perfusion and does
not impact ventilation. The airway is not obstructed, and unless the bleeding is in the lung
tissues (which is not mentioned in this question), breathing will not be impaired initially;
therefore, this would not be a priority NANDA. The hemorrhaging person is losing
volume, but it is due to the injury and actual blood loss rather than renal perfusion.
Cognitive Level: Analysis
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 3
8. If the trauma client was experiencing pain, the nurse may assess which of the
following objective data?
1. Facial grimacing and change in blood pressure or pulse
2. Flushed skin on neck and face, bradycardia
3. Hyperactive deep tendon reflexes and gripping hands
4. Increased anxiety and verbalizing impending doom
Correct Answer: Facial grimacing and change in blood pressure or pulse
Rationale: Facial grimacing and changes in breathing pattern, blood pressure, and pulse
along with diaphoresis and agitation are objective signs of pain. The patient will be in
tachycardia. With acute pain the deep tendon reflexes will not be affected. Patients with
pain have increased anxiety but usually do not verbalize impending doom. Patients
experiencing and internal hemorrhage or a cardiac abnormality many times verbalize
impending doom comments such as Im going to die.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3
9. When monitoring the trauma clients nutritional status, which of the following data
would be priority to assess?
1. Daily weights and presence of bowel sounds
2. Fluid-volume intake and food allergies
3. Ability to feed self and types of odor in the room
4. Family ability to assist with feedings and last documented bowel movement
Correct Answer: Daily weights and presence of bowel sounds
Rationale: Assessment of daily weights, 24-hour caloric intake, and presence of bowel
sounds, nausea and vomiting, or flatus are the objective priority data the nurse should
assess with regard to nutritional status. Fluid volume is important but is usually very low
in caloric intake and mainly prescribed for fluid and electrolyte balance. The ability to
feed self may be assessing the clients neurological and musculoskeletal status. If the
client requires rehabilitation, then family assistance may factor in at that point in the
clients recovery.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3
10. The trauma clients spinal cord must be protected from injury. Therefore, the nurse
should:
1. Apply a rigid cervical collar and logroll the client.
2. Keep the client on a backboard for the first 24 hours.
3. Keep the client supine until all diagnostic exams have been completed.
4. Keep the client flat and run a hand underneath to assess for posterior injuries.
Correct Answer: Apply a rigid cervical collar and logroll the client.
Rationale: For trauma clients, approximately 55% of spinal injuries occur in the cervical
region; therefore, a rigid cervical collar is a must to prevent further injury. Manual
stabilization of the spine is maintained while the client is turned using the logrolling
technique. All sources of bleeding must be ruled out, so the back of the patient must be
assessed. Diagnostic exams are done with lifting help to maintain a stable spine. A
backboard is removed shortly after the client arrives at the emergency department.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 4
12. Upon arrival at the trauma center, which of the following patients is least likely to
receive aggressive fluid resuscitation as an early intervention?
1. The patient with an open abdominal wound from a car accident
2. The patient whose hands were burned in a kitchen fire
3. The patient with a serious head injury from a fall
4. The patient whose leg was severed in an industrial accident
Correct Answer: The patient with an open abdominal wound from a car accident
Rationale: For a patient who is actively bleeding, increasing the arterial blood pressure
through administration of fluids can dislodge clots and interfere with the hemostatic
mechanisms that manage clotting. Current data suggest that aggressive fluid resuscitation
may be useful for patients with head injuries, thermal injuries, and isolated injury to an
extremity.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 4