Deck 51: The Pathophysiology of Primary and Secondary Traumatic Injury

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.

A) Circulation
B) Exposure
C) Breathing
D) Airway
E) Disability

Answer 1

Circulation
Breathing
Airway

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?

A) Level of consciousness
B) Anatomy of injury
C) Mechanism of injury
D) Special considerations

Answer 2

Anatomy of injury

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.

A) Airway clear
B) Best verbal response
C) Eyes open
D) Best pupillary response
E) Best motor response

Answer 3

Best verbal response
Eyes open
Best motor response

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?

A) Penetrating injury to the thigh, with visible bleeding
B) Open fracture of the arm, with severe pain
C) Open fracture of the leg, with visible deformity
D) Scalp laceration, unconscious, with normal respirations

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?

A) Stability of the cervical spine
B) Head and neck for severe bleeding
C) Patency of airway
D) Ability to breathe

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?

A) The effects of blood loss may be delayed.
B) Age-related changes in cognition may increase the risk of delirium.
C) A narrowed tolerance for a change in blood volume may occur.
D) The description of the mechanism of injury may be delayed due to word finding difficulties.

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.

A) A client with a closed head injury.
B) A client with severe laryngeal edema.
C) A client with projectile vomiting.
D) A client with cervical stenosis.
E) A client with multiple rib fractures.

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?

A) Inspecting the client's airway
B) Assessing the client's breathing
C) Obtaining the client's oxygen saturation
D) Stabilizing the client's cervical spine

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?

A) Anterior cord syndrome
B) Spinal shock
C) Brown-Séquard syndrome
D) Central cord syndrome

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.

A) Because of the client's body structure, there is an increased risk for lumbar injuries.
B) The client's spine has increased ligamentous laxity, increasing the risk for spinal cord injury.
C) Since this client is below the age of four, there is an increased risk of lumbar injury.
D) The client's vertebral column is vulnerable to deformity without fracture.
E) The most reliable way to determine the mechanism and anatomy of injury in this client is by imaging.

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?

A) The client's diaphragm will be displaced by up to 4 cm.
B) The client has a pleural effusion.
C) The client has a collapsed lung with air leakage into the chest.
D) The client will require surgical intervention.

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?

A) A right tension pneumothorax
B) A left open pneumothorax
C) A bilateral hemothorax
D) A flail chest

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.

A) This condition involves increased cardiac pressure leading to increased cardiac expansion.
B) This condition is due to blood accumulating in the pericardial sac.
C) This condition causes cardiac output to be dramatically reduced.
D) This condition can ultimately result in cardiac arrest.
E) This condition can be caused by any type of trauma to the mediastinum.

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?

A) Falls are a common cause of this type of injury.
B) Radiographic findings do not demonstrate evidence of this injury.
C) The immediate result of this injury is diffuse intracranial hemorrhage and loss of consciousness.
D) It is common for spontaneous recovery to occur within 1-2 months of the initial insult.

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.

A) Myocardial rupture
B) Endocarditis
C) Thromboembolism
D) Cardiac tamponade
E) Atrial fibrillation

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.

A) Fatigue
B) Vomiting
C) Diarrhea
D) Vertigo
E) Photophobia

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.

A) Esophagus
B) Distal carotid and vertebral arteries
C) Jugular veins
D) Pharynx
E) Spinal cord

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?

A) Large intestine
B) Stomach
C) Spleen
D) Liver

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?

A) An open displacement fracture of the femur
B) A dislocated hip with associated tibial fracture
C) A penetrating injury of the right hand
D) A contusion of the left arm with diffuse ecchymosis

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.

A) Abdominal injury requiring laparoscopic surgery
B) Hypotension at the time of admission
C) Airway injury requiring intubation
D) Head injury requiring neurosurgery
E) Pleural injury requiring chest tube placement