Question 1

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

Accepted Answer

A)   Ask the patient to state his or her name.
B)   Assess increasing intracranial pressure (ICP)  with facial fractures.
C)   Prepare for emergency tracheostomy.
D)   Perform a computerized tomography (CT)  scan of tissues of the neck. A

Question 2

An unconscious patient is brought to the emergency department. During the primary survey, the patient begins to moan when the left arm is moved. How should the nurse document this finding using the AVPU scale?

Accepted Answer

A)   A
B)   P
C)   U
D)   V B

Question 3

What should the nurse assess when evaluating breathing in a patient suspected of having thoracic trauma? Select all that apply.

Accepted Answer

A)   Jugular vein distention
B)   Symmetry of chest movement bilaterally
C)   Chest movements that rise and fall with breathing effort
D)   Respiratory rate, pattern, and effort
E)   Peripheral skin coloring A,B,C,D

Question 4

Which patient assessment data supports an open traumatic injury?

Accepted Answer

A)   A closed hip fracture that was caused by a fall
B)   A gunshot wound without penetration of the bullet due to the bullet-proof vest
C)   Near-drowning after falling through a frozen lake
D)   Burns over 30% of the body from a house fire

Question 5

A patient with traumatic injuries to the abdomen expresses the fear of dying. What can the nurse do to provide comfort to the patient at this time? Select all that apply.

Accepted Answer

A)   Face the patient when talking.
B)   State phrases that demonstrate care and comfort.
C)   Hold the patient's hand.
D)   Provide pain medication.
E)   Leave the patient to rest.

Question 6

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

A)   Provide brief hyperventilation.
B)   Take measures to increase intracranial pressures by Trendelenburg positioning.
C)   Prepare for emergency surgical repair.
D)   Contact the family to come say their last words with the patient.

Question 7

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

Accepted Answer

A)   Administer pain medication.
B)   Continue to monitor pulse oximetry and respiratory characteristics.
C)   Prepare for emergency intubation.
D)   Prepare the patient for chest tube insertion.
E)   Apply a dressing that is taped on three sides.

Question 8

For which situation should the nurse plan to prepare a patient with abdominal trauma for surgery?

Accepted Answer

A)   A suspected splenic injury having received 1 unit of blood
B)   A Grade III liver injury with stable vital signs
C)   A contusion to the kidney with a stable H & H
D)   A pelvic fracture with muscle rigidity of the abdominal wall

Question 9

A patient with a C6 spinal cord injury who received several liters of intravenous fluid continues to have a blood pressure of 78/50 mm Hg. What should the nurse anticipate being prescribed for this patient?

Accepted Answer

A)   Steroids
B)   Beta blocker
C)   Norepinephrine
D)   Packed red blood cells

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

A)   Using a manual ventilation bag
B)   Applying heated blankets
C)   Using the jaw thrust maneuver
D)   Assessing for history of asthma

Question 11

What should the nurse do to convey comfort to a trauma patient? Select all that apply.

Accepted Answer

A)   Explain and talk to the patient, and do not ignore the patient.
B)   Give clear, precise directions to follow.
C)   Directly look at the eyes of the patient when talking.
D)   Provide human contact, such as a reassuring touch.
E)   Give all details to get full cooperation.

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

A)   Blunt trauma from internal forces caused by acceleration
B)   Blunt trauma from external forces caused by deceleration
C)   Penetrating trauma from external forces caused by deceleration
D)   Penetrating trauma from internal forces caused by acceleration

Question 13

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

A)   Steroids will make the patient feel better overall and retain muscle strength due to its "muscle-bulking" effects.
B)   Steroids have few side effects and remove all symptoms while healing the problem.
C)   Steroids can lead to "road rage and anger outbursts" and therefore are avoided except under extreme emergencies.
D)   Steroids have not been used recently because of possible adverse outcomes.

Question 14

The nurse prepares to complete the secondary survey of a patient admitted with a traumatic chest injury. On what should the nurse focus when conducting this survey? Select all that apply.

Accepted Answer

A)   Full set of vital signs
B)   Comfort measures
C)   Head-to-toe assessment
D)   Assessment of posterior surfaces
E)   Exposure

Question 15

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

Accepted Answer

A)   Pulsus paradoxus
B)   Muffled heart sounds
C)   Hypotension
D)   Flat jugular veins
E)   Bounding peripheral pulses

Question 16

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

A)   Ability to respond to painful stimuli
B)   Vital signs
C)   Ability to respond to verbal command
D)   Level of consciousness or unconsciousness
E)   Oxygen saturation levels

Question 17

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

Accepted Answer

A)   Pain with swallowing, coughing, or hemoptysis
B)   Chest pain on inspiration
C)   Popping sound (crepitus)  in the throat when touching the skin by the trachea
D)   Hoarseness when talking

Question 18

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

Accepted Answer

A)   Provide oxygen 100% therapy through a nonrebreather mask.
B)   Restore the normal breathing pattern.
C)   Maintain a calm environment to decrease oxygen demands.
D)   Prevent sepsis.
E)   Maintain balanced hydration.

Question 19

The charge nurse delegates the completion of a secondary survey of a patient with traumatic injuries to a nurse being oriented to the emergency department. What should the charge nurse remind the new colleague to complete? Select all that apply.

Accepted Answer

A)   History
B)   Vital signs
C)   Comfort measures
D)   Head-to-toe assessment
E)   Nasogastric tube insertion

Question 20

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

Accepted Answer

A)   Fluid or blood continues to accumulate in the pericardial sac.
B)   The cause of the tamponade was persistent hypertension.
C)   Treatment by needle aspiration of the fluid in the sac is performed.
D)   A pericardial window is surgically created.

Exam 9: Care of the Patient Following Traumatic Injury