Essentials of Critical Care Nursing Care of Traumatic Injury Ch. 9
1. Correct Answer: 2
Rationale 1: Internal forces refer to stress or strain created within the body,
not from outside forces. Acceleration forces are when the increasing speed
hits someone who is stationary, such as a car hitting a person crossing the
street.
Rationale 2: Blunt trauma leaves the skin intact and damage to underlying
tissue, such as broken ribs. External forces are created by the mass of the
object and velocity of movement outside the body and the weight of the
person being pushed forward after the car hit something. Deceleration is the
force that stops or decreases the velocity of the moving victim, such as the
chest hitting the steering wheel.
Rationale 3: Penetrating wounds have an open wound and flail chests are
intact at the skin level.
Rationale 4: Penetrating wounds have an open wound and flail chests are
intact at the skin level. Internal forces refer to stress or strain created within
the body, not from outside forces.: A patient arrives in the emergency department
with a flail chest after a motor vehicle accident (MVA) in which the patient's chest
hit the steering wheel. The nurse realizes this injury is due to:
1. Blunt trauma from internal forces caused by acceleration
2. Blunt trauma from external forces caused by deceleration
3. Penetrating trauma from external forces caused by deceleration
4. Penetrating trauma from internal forces caused by acceleration
2. Correct Answer: 4
Rationale 1: This is an example of blunt trauma in which the skin is not broken,
but underlying tissue is damaged.
Rationale 2: This is an example of blunt trauma in which the skin is not broken,
but underlying tissue is damaged.
Rationale 3: This is an example of blunt trauma in which the skin is not broken,
but underlying tissue is damaged.
Rationale 4: Burns over 30% of the body from a house fire is an example of
an open or penetrating wound in which the skin does not remain intact.: Which
patient sustained an open traumatic injury? A patient with:
1. A closed hip fracture that was caused by a fall
2. A gun shot wound without penetration of the bullet due to the bullet-proof vest
3. Near-drowning after falling through a frozen lake
4. Burns over 30% of the body from a house fire
, Essentials of Critical Care Nursing Care of Traumatic Injury Ch. 9
3. Correct Answer: 1,3,4
Rationale 1: This is assessed under the disability part of the primary
assessment.
Rationale 2: Vital signs are classified under F-Full set of vital signs.
Rationale 3: This is assessed under the disability part of the primary
assessment.
Rationale 4: This is assessed under the disability part of the primary
assessment.
Rationale 5: Oxygen levels are covered under C-Circulation of the primary
assessment steps.: When performing a quick assessment to identify life-
threatening problems in a trauma patient, the nurse would include which
assessments under the D-Disability section?
Note: Credit will be given only if all correct choices and no incorrect choices are
selected.
Standard Text: Select all that apply.
1. Ability to respond to painful stimuli
2. Vital signs
3. Ability to respond to verbal command
4. Level of consciousness or unconsciousness
5. Oxygen saturation levels
4. Correct Answer: 3
Rationale 1: This action would be seen in step B-Breathing.
Rationale 2: This action would be seen in step E-Environment/exposure.
Rationale 3: Airway is covered under the A section. Maintaining an open
airway is the first priority. With a fracture or trauma to the neck, respirations
may be altered or prevented by bone or tissue misalignment. The jaw thrust
maneuver is the correct way to open the airway for a cervical spine injury.
Rationale 4: This action is performed in step H-Head-to-toe
assessment/medical history: What activities would the nurse implement under
the A section of assessment priorities when admitting a trauma patient with a
suspected spinal cord injury?
1. Using a manual ventilation bag
2. Applying heated blankets
3. Using the jaw thrust maneuver
4. Assessing for history of asthma
, Essentials of Critical Care Nursing Care of Traumatic Injury Ch. 9
5. Correct Answer: 2,3,4,5
Rationale 1: The chest wall injury would be a breathing survey assessment
because it focuses on thoracic trauma and the ability to ventilate and not
obstruct the airway itself.
Rationale 2: This can obstruct the airflow into or out of the lungs and cause
airway failure.
Rationale 3: This can obstruct the airflow into or out of the lungs and cause
airway failure.
Rationale 4: This can obstruct the airflow into or out of the lungs and cause
airway failure.
Rationale 5: This can obstruct the airflow into or out of the lungs and cause
airway failure.: Which risk factors could lead to the development of airway failure
if not recognized while assessing the airway of a trauma patient?
Note: Credit will be given only if all correct choices and no incorrect choices are
selected.
Standard Text: Select all that apply.
1. Chest wall injury
2. Displacement of the trachea (tracheal shift)
3. Aspiration of gastric contents
4. Foreign object occlusion of the throat/mouth
5. Swelling of soft tissue in the throat
6. Correct Answer: 1
Rationale 1: If the patient can state his name audibly then the airway is patent.
Rationale 2: ICP monitoring might be needed but it is not the first priority of
the nurse for airway issues.
Rationale 3: Emergency tracheostomy might be needed but it is still a second
action only if needed.
Rationale 4: CT scanning might be needed but it is not the first priority of the
nurse for airway issues.: Which nursing assessment would have highest priority
for early airway management of a trauma patient?
1. Ask the patient to state his name.
2. Assess increasing intracranial pressure (ICP) with facial fractures.
3. Prepare for emergency tracheostomy.
4. Perform a computerized tomography (CT) scan of tissues of the neck.
7. Correct Answer: 2
1. Correct Answer: 2
Rationale 1: Internal forces refer to stress or strain created within the body,
not from outside forces. Acceleration forces are when the increasing speed
hits someone who is stationary, such as a car hitting a person crossing the
street.
Rationale 2: Blunt trauma leaves the skin intact and damage to underlying
tissue, such as broken ribs. External forces are created by the mass of the
object and velocity of movement outside the body and the weight of the
person being pushed forward after the car hit something. Deceleration is the
force that stops or decreases the velocity of the moving victim, such as the
chest hitting the steering wheel.
Rationale 3: Penetrating wounds have an open wound and flail chests are
intact at the skin level.
Rationale 4: Penetrating wounds have an open wound and flail chests are
intact at the skin level. Internal forces refer to stress or strain created within
the body, not from outside forces.: A patient arrives in the emergency department
with a flail chest after a motor vehicle accident (MVA) in which the patient's chest
hit the steering wheel. The nurse realizes this injury is due to:
1. Blunt trauma from internal forces caused by acceleration
2. Blunt trauma from external forces caused by deceleration
3. Penetrating trauma from external forces caused by deceleration
4. Penetrating trauma from internal forces caused by acceleration
2. Correct Answer: 4
Rationale 1: This is an example of blunt trauma in which the skin is not broken,
but underlying tissue is damaged.
Rationale 2: This is an example of blunt trauma in which the skin is not broken,
but underlying tissue is damaged.
Rationale 3: This is an example of blunt trauma in which the skin is not broken,
but underlying tissue is damaged.
Rationale 4: Burns over 30% of the body from a house fire is an example of
an open or penetrating wound in which the skin does not remain intact.: Which
patient sustained an open traumatic injury? A patient with:
1. A closed hip fracture that was caused by a fall
2. A gun shot wound without penetration of the bullet due to the bullet-proof vest
3. Near-drowning after falling through a frozen lake
4. Burns over 30% of the body from a house fire
, Essentials of Critical Care Nursing Care of Traumatic Injury Ch. 9
3. Correct Answer: 1,3,4
Rationale 1: This is assessed under the disability part of the primary
assessment.
Rationale 2: Vital signs are classified under F-Full set of vital signs.
Rationale 3: This is assessed under the disability part of the primary
assessment.
Rationale 4: This is assessed under the disability part of the primary
assessment.
Rationale 5: Oxygen levels are covered under C-Circulation of the primary
assessment steps.: When performing a quick assessment to identify life-
threatening problems in a trauma patient, the nurse would include which
assessments under the D-Disability section?
Note: Credit will be given only if all correct choices and no incorrect choices are
selected.
Standard Text: Select all that apply.
1. Ability to respond to painful stimuli
2. Vital signs
3. Ability to respond to verbal command
4. Level of consciousness or unconsciousness
5. Oxygen saturation levels
4. Correct Answer: 3
Rationale 1: This action would be seen in step B-Breathing.
Rationale 2: This action would be seen in step E-Environment/exposure.
Rationale 3: Airway is covered under the A section. Maintaining an open
airway is the first priority. With a fracture or trauma to the neck, respirations
may be altered or prevented by bone or tissue misalignment. The jaw thrust
maneuver is the correct way to open the airway for a cervical spine injury.
Rationale 4: This action is performed in step H-Head-to-toe
assessment/medical history: What activities would the nurse implement under
the A section of assessment priorities when admitting a trauma patient with a
suspected spinal cord injury?
1. Using a manual ventilation bag
2. Applying heated blankets
3. Using the jaw thrust maneuver
4. Assessing for history of asthma
, Essentials of Critical Care Nursing Care of Traumatic Injury Ch. 9
5. Correct Answer: 2,3,4,5
Rationale 1: The chest wall injury would be a breathing survey assessment
because it focuses on thoracic trauma and the ability to ventilate and not
obstruct the airway itself.
Rationale 2: This can obstruct the airflow into or out of the lungs and cause
airway failure.
Rationale 3: This can obstruct the airflow into or out of the lungs and cause
airway failure.
Rationale 4: This can obstruct the airflow into or out of the lungs and cause
airway failure.
Rationale 5: This can obstruct the airflow into or out of the lungs and cause
airway failure.: Which risk factors could lead to the development of airway failure
if not recognized while assessing the airway of a trauma patient?
Note: Credit will be given only if all correct choices and no incorrect choices are
selected.
Standard Text: Select all that apply.
1. Chest wall injury
2. Displacement of the trachea (tracheal shift)
3. Aspiration of gastric contents
4. Foreign object occlusion of the throat/mouth
5. Swelling of soft tissue in the throat
6. Correct Answer: 1
Rationale 1: If the patient can state his name audibly then the airway is patent.
Rationale 2: ICP monitoring might be needed but it is not the first priority of
the nurse for airway issues.
Rationale 3: Emergency tracheostomy might be needed but it is still a second
action only if needed.
Rationale 4: CT scanning might be needed but it is not the first priority of the
nurse for airway issues.: Which nursing assessment would have highest priority
for early airway management of a trauma patient?
1. Ask the patient to state his name.
2. Assess increasing intracranial pressure (ICP) with facial fractures.
3. Prepare for emergency tracheostomy.
4. Perform a computerized tomography (CT) scan of tissues of the neck.
7. Correct Answer: 2
