Question 1

The trauma nurse has arrived at the scene of a large scale industrial accident. When assessing clients who have suffered trauma, the nurse understands that the primary survey begins with the assessment of which areas? Select all that apply.

Accepted Answer

The primary survey begins with the assessment of airway, breathing, and circulation.

Question 2

The trauma nurse is assigned to triage clients who have suffered trauma during a natural disaster. The nurse understands that according to the guidelines for field triage of injured patients, step 2 of triage includes which assessment?

Accepted Answer

Step 2 of the field triage guidelines involves assessing the anatomy of injury to determine the severity and prioritize treatment.

Question 3

The trauma nurse is assessing a client's level of consciousness with the Glasgow coma scale. Which components does the nurse recognize are part of the Glasgow coma scale? Select all that apply.

Accepted Answer

The Glasgow Coma Scale (GCS) is a tool used to assess the level of consciousness of a patient. It consists of three components: best verbal response, best motor response, and eyes open.

Question 4

The trauma nurse has arrived at the scene of a large accident and is preparing to transport clients to a trauma center. Which injury does the nurse immediately identify as requiring priority transport?

Accepted Answer

The unconscious client with a scalp laceration and normal respirations is prioritized due to the potential for a serious head injury, which can be life-threatening and requires immediate medical evaluation and intervention.

Question 5

The trauma nurse is performing a primary survey on a client who suffered trauma. Which assessment does the nurse determine will take the highest priority during the survey?

Accepted Answer

The primary survey in trauma care follows the ABCDE approach, where "A" stands for Airway. Ensuring the patency of the airway is the highest priority to ensure the client can breathe and receive oxygen.

Question 6

The nurse is assessing an older adult client for trauma following a motor vehicle accident. Which special considerations does the nurse understand must be taken for this client?

Accepted Answer

The answer of The nurse is assessing an older adult...

Question 7

The intensive care nurse is assessing a group of clients. Which clients does the nurse identify as likely requiring intubation? Select all that apply.

Accepted Answer

The answer of The intensive care nurse is assessing a...

Question 8

The nurse is assisting with the intubation of a client who has sustained a traumatic injury. What is the priority intervention for the nurse?

Accepted Answer

In a traumatic injury, especially with potential neck injury, stabilizing the cervical spine is crucial to prevent further spinal damage during intubation.

Question 9

The nurse is assessing a client with a spinal cord injury who is exhibiting loss of motor function, pain, and temperature sensation distal to the injury. Which complication does the nurse suspect?

Accepted Answer

Anterior cord syndrome is characterized by the loss of motor function, pain, and temperature sensation below the level of injury, while proprioception and vibration sense are preserved.

Question 10

The nurse is assessing a neonate for a suspected spinal cord injury. What age-related considerations does the nurse take during the assessment? Select all that apply.

Accepted Answer

The answer of The nurse is assessing a neonate for...

Question 11

The nurse is caring for a client diagnosed with a pneumothorax. Which statement about this condition does the nurse know to be true?

Accepted Answer

A pneumothorax is a condition where air leaks into the space between the lung and chest wall, causing the lung to collapse.

Question 12

The nurse cares for a client who has sustained a trauma. While assessing the client, the client begins to exhibit dyspnea, distended neck veins, and tracheal deviation to the left side. What condition does the nurse expect?

Accepted Answer

The symptoms of dyspnea, distended neck veins, and tracheal deviation to the left side are indicative of a right tension pneumothorax, where air is trapped in the pleural space on the right side, causing pressure that shifts the trachea to the left.

Question 13

The nurse is caring for a client with pericardial tamponade. Which statements about the mechanism of this condition does the nurse know to be true? Select all that apply.

Accepted Answer

- Pericardial tamponade is a condition in which blood accumulates in the pericardial sac, which surrounds the heart. - This accumulation of blood can cause increased pressure on the heart, leading to decreased cardiac output and ultimately cardiac arrest.

Question 14

The nurse is caring for a client with a diffuse axonal injury. Which statement about the client's condition does the nurse know to be true?

Accepted Answer

Diffuse axonal injury often does not show up on standard radiographic imaging like CT scans, as it involves microscopic damage to the brain's white matter tracts.

Question 15

The nurse is caring for a client diagnosed with a myocardial contusion. The nurse understands that which complication can result from this condition? Select all that apply.

Accepted Answer

The answer of The nurse is caring for a client...

Question 16

The nurse is providing education to a client with postconcussive syndrome about the symptoms associated with traumatic brain injuries. Which symptoms will the nurse review with the client? Select all that apply.

Accepted Answer

Fatigue, vomiting, vertigo, and photophobia are common symptoms associated with traumatic brain injuries and postconcussive syndrome. Diarrhea is not typically related to brain injuries.

Question 17

The nurse is performing an assessment on zone III of the neck on a client with a cervical spine injury. The nurse understands that zone III is comprised of which structures? Select all that apply.

Accepted Answer

The answer of The nurse is performing an assessment on...

Question 18

The nurse is caring for a client with penetrating abdominal trauma. Which organ does the nurse identify as most commonly affected by this type of injury?

Accepted Answer

The liver is the most commonly affected organ in penetrating abdominal trauma due to its large size and location in the upper right quadrant of the abdomen.

Question 19

The trauma nurse has arrived at the site of a major accident and is assessing several clients with extremity injuries. Which injury requires immediate intervention by the nurse?

Accepted Answer

An open displacement fracture of the femur is a critical injury due to the risk of significant blood loss and potential for infection, requiring immediate intervention.

Question 20

The emergency department nurse has received a call from an incoming ambulance about a client who sustained a pelvic fracture. Which concomitant findings does the nurse understand to significantly increase the mortality rate in this client? Select all that apply.

Accepted Answer

The answer of The emergency department nurse has received a...

Quiz 51: The Pathophysiology of Primary and Secondary Traumatic Injury