Nursing Care: Trauma By System – Questions &
Solutions
Match the types of traumatic brain injury with the appropriate description.
Correct Ans - Localized injury to the brain limited to the area of impact:
BRAIN CONTUSION
May cause a contusion or laceration to the brain tissue: DEPRESSED SKULL
FRACTURE
Venous bleeding between the dura mater and inner surface of the brain:
EPIDURAL HEMATOMA
Venous bleeding between the dura mater and the arachnoid layer of the
meninges: SUBDURAL HEMATOMA
A client is admitted to the emergency department after being hit by a car. A
fracture of the cervical spine is suspected. What is the priority nursing
action? Correct Ans - Immobilize the cervical spine
The nurse is caring for four clients. Which should the nurse assess first?
Correct Ans - client with a new left lower leg cast reporting that it is too
tight, and he cannot feel his toes
A client arrives at the emergency department following a head injury and
loss of consciousness at the scene.
Place the nursing actions in the order of highest to lowest priority.
Correct Ans - Confirm patency of the airway.
Maintain cervical spine stabilization.
Establish intravenous (IV) access and administer isotonic fluids.
Assess for signs of increased intracranial pressure.
Monitor for changes in neurologic status.
Anticipate the need for hematoma evacuation.
A client with a spinal cord injury suddenly develops a throbbing headache,
diaphoresis and flushing above the level of the injury, and severe
hypertension. Heart rate is 40 beats/minute.
Place the nursing actions in the order of highest to lowest priority.
Correct Ans - Sit the client upright.
Check for bladder and bowel distention.
Loosen restrictive clothing.
Solutions
Match the types of traumatic brain injury with the appropriate description.
Correct Ans - Localized injury to the brain limited to the area of impact:
BRAIN CONTUSION
May cause a contusion or laceration to the brain tissue: DEPRESSED SKULL
FRACTURE
Venous bleeding between the dura mater and inner surface of the brain:
EPIDURAL HEMATOMA
Venous bleeding between the dura mater and the arachnoid layer of the
meninges: SUBDURAL HEMATOMA
A client is admitted to the emergency department after being hit by a car. A
fracture of the cervical spine is suspected. What is the priority nursing
action? Correct Ans - Immobilize the cervical spine
The nurse is caring for four clients. Which should the nurse assess first?
Correct Ans - client with a new left lower leg cast reporting that it is too
tight, and he cannot feel his toes
A client arrives at the emergency department following a head injury and
loss of consciousness at the scene.
Place the nursing actions in the order of highest to lowest priority.
Correct Ans - Confirm patency of the airway.
Maintain cervical spine stabilization.
Establish intravenous (IV) access and administer isotonic fluids.
Assess for signs of increased intracranial pressure.
Monitor for changes in neurologic status.
Anticipate the need for hematoma evacuation.
A client with a spinal cord injury suddenly develops a throbbing headache,
diaphoresis and flushing above the level of the injury, and severe
hypertension. Heart rate is 40 beats/minute.
Place the nursing actions in the order of highest to lowest priority.
Correct Ans - Sit the client upright.
Check for bladder and bowel distention.
Loosen restrictive clothing.
