- A nurse participates in a public safety education program to encourage people to wear seatbelts. The nurse is participating in:
- Primary prevention
- Secondary prevention
- Tertiary prevention
- Quarternary prevention
- A nurse is caring for a patient who was thrown from his bicycle and collided with the side of a building. The nurse suspects the injuries the patient has sustained result from:
- Blunt trauma
- Penetrating trauma
- Blast trauma
- Thermal trauma
- A patient has survived a blast trauma. The nurse is cleansing a wound the patient received when he was struck by a piece of metal shrapnel. The nurse recognizes this injury as
- A nurse is performing the primary survey of a patient just admitted to the ED from the field. After checking the patient’s respiratory status, what is the nurse’s next priority action?
- Assess neurologic status
- Cover the patient with a warming blanket
- Assess peripheral pulses and capillary refill
- Expose the patient and observe for injuries
- The nurse stops at the scene of a car crash and is attending to a man who was not wearing a seatbelt and collided with his steering wheel and windshield. The nurse prepares to maintain the man’s airway. The nurse knows the best technique to use is:
- Perform an emergency tracheotomy
- Turn his head to the left side and open the jaw
- Chin-tilt head-lift maneuver
- Modified jaw-thrust technique
- The nurse is caring for a trauma patient who is experiencing hypovolemia. The nurse anticipates which initial intervention?
- Administer 1 unit of packed red blood cells
- Administer D5/W according to the 3:1 rule
- Administer Lactated Ringer’s according to the 3:1 rule
- Administer Lactated Ringer’s according to the 1:1:1 rule
- The nurse is caring for a patient receiving extensive fluid resuscitation. The nurse anticipates which of the following complications? (Select all that apply)
- Electrolyte imbalances
- Increased ICP
- Dilutional coagulopathies
- After stabilizing the patient, the nurse prepares to educated the patient about the administration of which of the following vaccines?
- The nurse is caring for a patient with a suspected abdominal bleed. The nurse anticipates which of the following tests initially?
- Chest x-ray
- The nurse is caring for a patient with a mediastinal shift to the left, decreased breath sounds on the right, and agitation. The nurse anticipates which of the following therapies:
- Three-side occlusive dressing
- Chest tube in the right lung to drain blood
- Needle thoracostomy of the right lung at the 2nd intercostal space
- Emergency tracheostomy
- A nurse is caring for a patient recovering from an adjacent fracture of three ribs on the right side. The nurse encourages the client to perform which of the following? (Select all that apply)
- Avoid the valsalva maneuver
- Splint with a pillow when coughing
- Incentive spirometry
- Take prophylactic antibiotics
- The nurse is caring for a patient with cardiac tamponade. The nurse expects which of the following signs? (Select all that apply)
- Pulsus paradoxus
- Muffled heart sounds
- The nurse notes a patient who received blunt trauma to the the abdominal region has a blueish umbilicus. The nurse correctly documents the patient as having:
- A positive Grey Turner’s sign
- A positive Kehr’s sign
- A positive Cullen’s sign
- A positive Babinski’s sign
- A patient who received a blunt trauma injury presents with hematuria, flank pain, bladder distention, and dysuria. The nurse suspects the patient has:
- Renal trauma
- Ruptured spleen
- Aortic aneurysm
- GI bleed
- The nurse is caring for a trauma patient and notes ecchymosis in the periorbital region and behind the ears. The nurse suspects
- Anaphylactic shock
- Skull fracture
- Cervical spine injury
- Domestic abuse
- A nurse preceptor is observing a new nurse caring for a patient with a skull fracture and CSF drainage. The preceptor intervenes when the new nurse. . .
- Allows CSF to flow freely
- Instructs the patient to blow the nose gently
- Inserts an orogastric tube
- Places gauze under the patient’s nose
- The nurse is caring for a patient with a traumatic brain injury. All of the following are appropriate interventions except:
- Positioning the HOB at 30 degrees
- Administering a cooling blanket
- “Log rolling” the patient when repositioning
- Encouraging the patient to cough and deep breathe regularly
- The nurse’s priority intervention when caring for a patient with traumatic brain injury is:
- Reduce environmental stimuli
- Provide oxygenation
- Administer pain medications
- Offer nutritional support
- The nurse recognizes which of the following as the gold standard for measuring ICP:
- Intraparenchymal fiberoptic catheter
- Licox catheter
- Epidural sensor
- The nurse preceptor instructs a new nurse in how to level a ventriculostomy. The nurse preceptor tells the new nurse to level it at the level of
- Fourth intercostal space
- Tragus of the ear
- Foramen magnum
- The nurse is caring for a patient with a traumatic brain injury. The nurse recognizes which early sign of increased ICP?
- Hypertension with a widening pulse pressure
- Irregular respirations
- Altered level of consciousness
- The nurse is caring for a patient with increased ICP. The nurse performs all of the following interventions except:
- Maintains CPP <70
- Spaces nursing activities
- Keeps HOB at 30-45 degrees
- Maintains ICP <15
- The nurse is talking with the family of a patient with increased ICP. The nurse correctly informs the family
- “It is important to keep activities with the patient clustered to allow for periods of rest.”
- “You can assist the patient in rotating his head slowly side to side to prevent muscle atrophy.”
- “Please keep the lights in the patient’s room low.”
- “Remind the patient to perform his cough and deep breathing exercises every hour.”
- The nurse correctly identifies which of the following as an inappropriate intervention for a patient with increased ICP:
- Setting the mechanical ventilator to provide limited hyperventilation
- Administering Mannitol
- Providing a warming blanket
- Sedation with propofol
- A student nurse is assessing LOC in a patient with a traumatic brain injury and possible cervical spine injury. The RN intervenes when the student
- Applies nail bed pressure
- Checks for the “doll eyes” reflex
- Performs a sternal rub
- Checks PERRLA
- The nurse is caring for a patient with a spinal cord injury and neurogenic shock. The nurse anticipates administering (Select all that apply)
- Anti-seizure medications
- A patient has complete paralysis below the umbilicus. The nurse would refer the patient to
- Sexual counseling
- Speech therapy
- Ophthalmologic surgeon
- The nurse is caring for a patient with a suspected spinal cord injury. The nurse anticipates which of the following tests? (Select all that apply)
- CT Scan
- The nurse is caring for a patient with a spinal cord injury. All of the following are appropriate interventions except:
- Log roll the patient when repositioning
- Avoid cleaning around the pin sites of cervical traction to keep the area dry
- Maintain MAP 85-90
- Administer high dose of methylprednisolone
- Which statement by a patent with a spinal cord injury indicates a need for further teaching?
- “I am receiving Levophed (norepinephrine) to keep my blood pressure up.”
- “I may have to wear a Halo device all the time while my injury heals”
- “The steroid will help to preserve function where I am injured”
- “I will take imodium to prevent diarrhea.”
- A patient with a spinal cord injury has a blood pressure of 200/120, HR 50, and is anxious and complaining of nausea.The nurse should (select all that apply)
- Contact the HCP
- Administer Nifedipine (Procardia)
- Have the patient lie flat
- Loosen tight clothing
- The nurse is teaching a group of residents in an assisted living facility about modifiable risk factors for brain attack (stroke). The nurse focuses on (Select all that apply)
- A nurse is assessing a patient experiencing a brain attack. The nurse knows all of the following are priority assessments except
- CT w/o contrast
- Asking a family member when patient was last seen normal
- Detailed health history
- Glascow Coma Scale
- A patient arrives at the ED complaining of sudden, progressive unilateral numbness, dizziness, visual disturbances, and nausea and vomiting. The nurse suspects
- Intracranial hemmorhage
- Subarachnoid hemmorhage
- Ischemic stroke
- Chronic brain attack
- The nurse is caring for a patient with an ischemic stroke. The nurse anticipates which medication order initially
- Osmotic diuretics
Secondary prevention aims to minimize the impact of a traumatic event, such as helmets and seatbelts. Primary prevention aims to prevent the traumatic event itself, such as efforts to keep people from drinking and driving. Tertiary prevention maximizes patient outcomes after a traumatic events, for example emergency response systems. There is no quarternary prevention.
Blunt trauma refers to acceleration/deceleration, shearing, crushing, and compression injuries.
Secondary injury of a blast injury refers to injuries received from debris impaling the body. Primary injury refers to tissue damage resulting from changes in air pressure. Tertiary injury results from the body being thrown against something due to the force of the explosion. Quaternary injury refers to injuries sustained from biochemical and thermal exposure.
According to the ABCDE of the primary survey, the systematic order for assessment is airway, breathing, circulation, disability of the nervous system, and exposure of the patient.
The modified jaw-thrust technique is the best way to secure a patent airway in a patient with a suspected cervical spine injury.
Lactated Ringer’s (or normal saline) are the fluid of choice of choice for initial resuscitation efforts. Administer using the 3:1 rule (3 mL crystalloid for each mL of blood loss) at 1 L/minute. Blood products may then be given based on patient response.
- 1, 2, 4
Trauma patients often receive a tetanus vaccine if they are not up to date or if the status of their tetanus immunization is unknown, because traumatic injuries are rarely “clean.”
FAST provides the best rapid, noninvasive means to determine accumulation of free fluid in the peritoneal cavity or pericardial sac. If fluid is found, the patient may then be sent for a CT.
The patient is experiencing a tension pneumothorax of the right lung, as evidenced by a mediastinal shift to the left and decreased breath sounds on the right. Needle thoracostomy (often followed by chest tube insertion) is the appropriate intervention for a tension pneumothorax. A three-side occlusive dressing is appropriate for an open pneumothorax.
- 2, 3
Coughing and deep breathing and incentive spirometry are appropriate interventions for a patient recovering from flail chest. Splinting with a pillow when coughing would be appropriate to decrease pain associated with cough/deep breathe exercises.
- 1, 2, 4, 5
Hypotension, muffled heart sounds, and elevated venous pressure (JVD) are part of Beck’s triad. Pulsus paradoxus is also a sign of cardiac tamponade.
Cullen’s sign is a blueish umbilicus. Grey Turner’s sign is the presence of blueish flanks. Kehr’s is shoulder pain when lying down with the legs elevated (sign of ruptured spleen). Babinski’s is the fanning of the toes seen in nervous system damage.
These findings are consistent with renal trauma. The patient may also have a positive Grey Turner’s sign.
Periorbital ecchymosis, or “racoon eyes,” and ecchymosis behind the ears (Battle’s sign) are classic signs of a skull fracture, along with postnasal serosanguinous drainage (rhinorrhea) and otorrhea of CSF, halo sign, and blood in the inner ear.
To avoid increasing ICP, the patient should be instructed not to blow their nose. Letting CSF flow freely (not packing the nose/ear) and placing gauze under the nose for drainage are appropriate interventions. Tubes should be inserted through the mouth instead of the nose, so inserting an orogastric tube in place of a nasogastric tube is appropriate.
The patient should be instructed to avoid coughing, sneezing, and the valsalva maneuver to prevent increases in ICP. All other interventions are appropriate for a patient with TBI.
The priority intervention is to provide oxygenation to maintain cerebral perfusion.
A ventriculostomy should be leveled at the foramen of Monro, the exterior reference point for which is the tragus of the ear.
Altered LOC is the best and earliest indicator of increased ICP. The others are part of Cushing’s triad, which is a late sign.
The nurse should maintain CPP >70. All other interventions are appropriate.
Decreasing environmental stimuli, such as bright lights, helps to prevent increases in ICP. Activities should be spaced to prevent increases in ICP from overstimulation. The head should be maintained in a neutral position. The patient should avoid coughing, sneezing, and the valsalva maneuver.
Therapeutic hypothermia may be used in a patient with increased ICP to reduce metabolic demands. All other options are appropriate interventions.
This procedure is contraindicated in a patient with a suspected C-spine injury, and is also usually performed by the physician. All other options are appropriate interventions.
- 3, 4
These medications help to counteract the loss of SNS, which results in hypotension and bradycardia, as well as peripheral vasodilation.
Due to complete paralysis of the lower half of the body, the patient will likely be referred to sexual counseling.
- 1, 4
These are both appropriate tests to check for a spinal cord injury. The patient may also receive a diagnostic x-ray. FAST and DPL are appropriate to check for abdominal bleeding.
Pin sites should be carefully cleaned to prevent infection. All other interventions are appropriate.
Patients should be on a bowel regimen for two reasons: 1) they may have a loss of reflex and sphincter control after injury, and 2) fecal impaction and constipation can cause autonomic dysreflexia
- 1, 2, 4
The patient is experiencing autonomic dysreflexia. The nurse should elevate the HOB at 45 degrees or sit the patient upright. All other interventions are appropriate.
- 2, 4
Smoking and hypertension are modifiable risk factors for brain attack (stroke). Age is a risk factor, but it is not modifiable. Polypharmacy is not a known risk factor.
Although this is important, a detailed health history is not a priority when a patient is experiencing a brain attack.
A patient with ICH will complain of sudden focal neurologic deficits that progress quickly and may be unilateral or bilateral numbness/weakness, sensory losses, dizziness, visual and speech defects, gait disturbances, change in LOC, and nausea and vomiting. A patient with a SAH will complain of a terrible headache, nausea and vomiting, stiff neck, loss of consciousness, and sentinel headaches.
Ischemic stroke is treated with rT-PA to break up the clot in the brain. Antihypertensives and osmotic diuretics are administered in hemorrhagic stroke. Mannitol is given for increased ICP.