Question 1

A trauma patient is hemorrhaging from multiple gunshot wounds to the lower abdomen. The nurse provides care based on which priority nursing diagnosis (NDX)?

Accepted Answer

The top priority nursing diagnosis for a trauma patient with active hemorrhage is Ineffective Tissue Perfusion related to hypovolemia. This diagnosis reflects the urgent need to restore blood volume to prevent further tissue damage and organ failure. The other options are important but do not have the same immediate priority in this situation.

Question 2

A patient was an unrestrained driver in a frontal-impact motor vehicle collision. The nurse would expect which finding?

Accepted Answer

In a frontal-impact motor vehicle collision, the chest is most commonly injured. This can result in multiple rib fractures, which can cause paradoxical movement of the chest.

Question 3

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

Accepted Answer

Airway patency is the first priority in any trauma patient as it is essential for oxygenation and ventilation. In a patient with abdominal trauma, compromised airway can occur due to potential vomiting or aspiration. Once the airway is secured, the nurse should proceed with assessing the other areas of concern.

Question 4

A patient was involved in an automobile accident in which the car left the road and hit a bridge. Which information provided by the paramedics would the nurse evaluate as important in understanding the mechanism of injury? Select all that apply.

Accepted Answer

The speed of the vehicle (A) indicates the force of impact, the lack of intrusion (B) suggests the passenger space was preserved, the deployment of airbags (D) indicates additional protection, and wearing a seatbelt (E) reduces the risk of injury. These factors help assess the potential severity and type of injuries.

Question 5

A trauma patient who experienced blunt cardiac injury from a steering wheel should be assessed for cardiac tamponade. The nurse would assess for which clinical manifestations? Select all that apply.

Accepted Answer

Neck vein distention, muffled heart sounds, and hypotension are classic signs of cardiac tamponade, which occurs when fluid accumulates in the pericardium, compressing the heart and impairing its function.

Question 6

The patient was a restrained front seat passenger in a car crash. Which findings would the nurse evaluate as indicating possible internal injury from the seatbelt? Select all that apply.

Accepted Answer

The answer of The patient was a restrained front seat...

Question 7

A patient presents to the emergency department with brisk hemorrhage from a laceration on the lower leg. How should the nurse address the hemorrhage?

Accepted Answer

The best initial intervention for a brisk hemorrhage from a laceration is to apply direct manual pressure on the wound. This will help to control the bleeding until the patient can be further assessed and appropriate interventions can be implemented. Taping ABD pads over the wound or packing ice directly on the wound are not effective interventions for controlling hemorrhage. A tourniquet should only be used as a last resort in extreme situations.

Question 8

A patient has been stabbed just below the left nipple. The nurse would assess for damage to which structures? Select all that apply.

Accepted Answer

The stab wound below the left nipple could potentially damage the lung, heart, spleen, and diaphragm due to their anatomical proximity to the area. The subclavian vein is not typically located in this region.

Question 9

A patient is transported by ambulance with massive hemorrhage from a gunshot injury. Immediate transfusion of packed red blood cells is indicated. Which blood does the nurse anticipate transfusing?

Accepted Answer

In emergency situations, when the patient's blood type is not yet known, type O blood can be transfused as it is considered the universal donor blood type. This is because type O red blood cells do not have A or B antigens on their surface, which reduces the risk of a transfusion reaction. Type AB blood is not a good choice in this scenario as it is considered the universal recipient blood type and may not have enough readily available blood products.

Question 10

A gunshot wound victim is "dumped" in the parking lot of the emergency department (ED). What is the nurse's priority action?

Accepted Answer

The nurse's priority action should be to initiate airway management with cervical spine immobilization to ensure the patient's breathing is not compromised and to prevent any further injury to the spine. Once the patient's airway has been stabilized, the nurse can call for assistance and a stretcher to bring the patient into the ED. Assessment of consciousness can also occur simultaneously. Security should be notified after the patient has been stabilized and secured.

Question 11

The nurse would aggressive fluid resuscitation as an early intervention for which patient?

Accepted Answer

Aggressive fluid resuscitation is an early intervention for patients experiencing hemorrhagic shock, such as in the case of an open abdominal wound from a car crash. It is not typically used for head injuries, burns, or severed limbs.

Question 12

The nurse works in an emergency department in a town with a large proportion of retired persons. The nurse should consider which difference between older and younger adults as it pertains to emergency care?

Accepted Answer

Older patients have an increased incidence of subdural hematomas because their veins are more fragile and less elastic compared to those of younger patients. This is important for the nurse to consider when assessing and treating elderly patients in the emergency department, as they may be at higher risk for intracranial bleeding due to falls or other injuries.

Question 13

A child ran into the street and was struck by a car. Which finding, typical for this mechanism of injury, would the nurse anticipate assessing?

Accepted Answer

When a child is struck by a car, chest or femur injuries may occur where the bumper may have impacted the child. Lower extremity fractures are less common in this mechanism of injury, as the wheels may not necessarily run over the child. Kidney injury and liver injuries are also less common in this mechanism of injury unless there is an additional component of crush injury or penetration.

Question 14

A patient is brought to the emergency department after being involved in a motor vehicle crash. Which assessment would indicate to the nurse that FAST examination will likely be necessary?Select all that apply.

Accepted Answer

The FAST examination (Focused Assessment with Sonography in Trauma) is used to quickly assess for the presence of free fluid or blood in the abdominal cavity, pericardium, or pleural space, which can be indicative of internal bleeding from trauma. Ecchymoses over the abdomen (A), involvement as a restrained driver in a head-on crash (C), and complaints of chest wall tenderness (E) are all potential indications for the need for a FAST examination. Complaints of neck pain (B) and lower leg lacerations and fractures (D) would not necessarily require a FAST exam.

Question 15

A patient sustained multiple fractures and contusions when hit by a car while walking across the street. He says, "How can I be hurt so badly? The car barely hit me." How should the nurse respond?

Accepted Answer

The nurse should explain to the patient that the car's movement and energy were transferred to the patient's body upon impact, resulting in numerous fractures and contusions. This explanation helps the patient understand the severity of the injuries sustained even if the car was moving at a slow pace. Option B and D are incorrect because the information provided about the patient's diabetes or age has no direct correlation to the injury severity. Option C is incorrect because assuming that the patient doesn't remember the accident can be perceived as dismissive or disrespectful.

Question 16

The nurse is teaching a community education class on prevention of neck injury. Which information would the nurse include in this teaching?

Accepted Answer

The answer of The nurse is teaching a community education...

Question 17

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 distention with a tracheal deviation. The nurse should act quickly to treat which probable condition?

Accepted Answer

The symptoms described suggest tension pneumothorax, which can occur as a result of trauma and has the potential to be life-threatening. Prompt treatment, such as needle decompression or chest tube insertion, is necessary to relieve pressure on the lungs and prevent further complications.

Question 18

A patient was the restrained front seat passenger in a slow-speed automobile crash in which the car was struck in the middle of the passenger side. Where would the nurse look first for injuries in this patient?

Accepted Answer

The patient was restrained in the front passenger seat, and the car was struck on the middle of the passenger side. This suggests that the right side of the body (head, arm, hip) would have been closer to the impact and therefore more likely to be injured. However, it is important to assess the patient fully for all potential injuries.

Question 19

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. Which intervention does the nurse prioritize?

Accepted Answer

The patient's dyspnea, cyanosis, and subcutaneous emphysema suggest that air is becoming trapped within the chest cavity, which can quickly lead to airway compromise and respiratory arrest. Intubation should be prioritized to secure the airway and ensure adequate ventilation/oxygenation. Notification of next of kin is important, but is not the immediate priority. X-ray of the cervical spine may be important for determining if there is any spinal cord injury, but is also not the immediate priority. Administration of an IV beta blocker is not indicated in this situation.

Question 20

The nurse should protect the trauma patient's spinal cord. Which action should the nurse take?

Accepted Answer

The best choice would be to apply a rigid cervical collar and logroll the patient. This is because the cervical spine can be easily injured in trauma, and a cervical collar can help stabilize the neck. Logrolling involves turning the patient as a unit to prevent movement of the spine, while protecting the head and neck in particular. Keeping the patient supine until diagnostic exams are completed is also important to prevent further injury, but using a cervical collar and logrolling the patient provides more immediate protection to the spinal cord.

Quiz 67: Caring for the Patient With Multisystem Trauma

A trauma patient is hemorrhaging from multiple gunshot wounds to the lower abdomen. The nurse provides care based on which priority nursing diagnosis (NDX) ?