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[Osborn] chapter 74
Learning Outcomes [Number and Title ]
Learning Outcome 1
Discuss the correlation between mechanism of injury with
patient assessment based on an understanding of the kinematics
of trauma.
Learning Outcome 2
List the priorities of the primary and secondary surveys.
Learning Outcome 3
Explain the rationale for the tertiary survey.
Learning Outcome 4
Compare and contrast special considerations experienced
during the initial resuscitation.
Osborn, et al., Test Item File for Medical-Surgical Nursing:
Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
Full file at http://testbank360.eu/test-bank-medical-surgical-nursing-1st-osborn
1. In the event that an unrestrained passenger was injured in a frontal-impact collision,
the nurse should assess for:
1. Paradoxical movement of the chest caused by multiple rib fractures.
2. Unstable pelvic structure causing severe pain on palpation.
3. Unequal pulses in the lower extremities due to possible femur fracture.
4. Neck muscle spasms caused by hyperextension of the neck.
Correct Answer: Paradoxical movement of the chest caused by multiple rib fractures.
Rationale: If the passenger has no seatbelt or the airbag does not deploy, the body might
travel down and under the steering wheel or over the steering wheel, incurring injury at
the body’s point of impact. Thus, rib fractures are common and can result in flailed chest
injuries. Pelvic fractures are usually a result of frontal-impact collision when a seatbelt is
being worn. Femur fractures may occur when motorcycles are involved in a collision.
Hyperextension of the neck usually occurs in rear-end-impact collisions.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1
Osborn, et al., Test Item File for Medical-Surgical Nursing:
Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
Full file at http://testbank360.eu/test-bank-medical-surgical-nursing-1st-osborn
2. If a child is struck by a car, the nurse should assess for:
1. Chest or femur injuries where the bumper may have impacted the child.
2. Liver injuries on the right side due to impact by the vehicle.
3. Lower extremity fracture caused by the wheels running over the child.
4. Kidney injury due to the impact of the vehicle on the lower back.
Correct Answer: Chest or femur injuries where the bumper may have impacted the child.
Rationale: Children tend to freeze and face the vehicle and therefore end up with more
frontal injuries than adults. So, depending on the height of the child and the height of the
vehicle bumper, the impact occurs on the chest or femur. Adults usually try to escape and
turn away from the vehicle, thus sustaining lateral injuries on the side of impact, such as
liver, kidney, or lower extremity.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1
Osborn, et al., Test Item File for Medical-Surgical Nursing:
Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
Full file at http://testbank360.eu/test-bank-medical-surgical-nursing-1st-osborn
3. In addition to lung or heart damage, a stab wound inflicted at or below nipple level
may also cause damage to the:
1. Abdomen.
2. Trachea.
3. Larynx.
4. Urinary bladder.
Correct Answer: Abdomen.
Rationale: During expiration, the dome of the diaphragm reaches as high as the fifth rib.
Stab wounds to the chest at or below the level of the nipple should be inspected for
abdominal injury as well. The trachea, larynx, and bladder would not be within reach of
the typical stab wound instrument.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1
Osborn, et al., Test Item File for Medical-Surgical Nursing:
Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
Full file at http://testbank360.eu/test-bank-medical-surgical-nursing-1st-osborn
4. If a trauma patient arrives in the emergency department (ED) via ambulance, the
priority nursing assessment would include:
1. Airway management with cervical spine immobilization.
2. Insertion of two large-bore IV catheters.
3. Insertion of Foley catheter.
4. Assessing level of consciousness and ability to follow commands.
Correct Answer: Airway management with cervical spine immobilization.
Rationale: Airway is always priority, with consideration of maintaining the cervical spine
in a midline position. First, the airway is assessed for patency; it may be obstructed by
blood, displacement of tissue, etc.. The other interventions are important as well, but
unless tissues are being oxygenated, death will occur within minutes.
Cognitive Level: Synthesis
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 2
Osborn, et al., Test Item File for Medical-Surgical Nursing:
Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
Full file at http://testbank360.eu/test-bank-medical-surgical-nursing-1st-osborn
5. For the emergency department client who has external hemorrhage, the most
appropriate way to control the bleeding is for the nurse to:
1. Apply direct manual pressure on the wound.
2. Apply a tourniquet tight enough to stop all the external bleeding.
3. Pack the wound with ice directly on the wound to cause vasoconstriction.
4. Tape ABD pads over the wound and reinforce when they become saturated.
Correct Answer: Apply direct manual pressure on the wound.
Rationale: Direct pressure is the best and easiest way to control external hemorrhage. A
tourniquet can cause crush injury to tissues and distal ischemia. Ice can cause tissue
damage as well. Applying dressings without compression will not control the bleeding.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 2
Osborn, et al., Test Item File for Medical-Surgical Nursing:
Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
Full file at http://testbank360.eu/test-bank-medical-surgical-nursing-1st-osborn
6. A trauma client who has experienced a blunt cardiac injury from a steering wheel
should be assessed for cardiac tamponade. Which of the following clinical manifestations
would the nurse be assessing for?
1. Neck vein distention, muffled heart sounds, hypotension
2. Jugular vein distention, bounding pulse, harsh murmur
3. Bilateral upper arm distention, hypertension, edema of the face
4. Absent breath sounds on the left, apical pulse displaced to the left, S3 heart
gallop
Correct Answer: Neck vein distention, muffled heart sounds, hypotension
Rationale: Neck vein distention is caused by elevated central venous pressure, muffled
heart sounds is due to the amount of blood surrounding the heart, and hypotension is due
to blood loss (i.e., shock). Bounding pulse is usually seen in hypervolemic states.
Bilateral arm distention is usually caused by pressure placed on the superior vena cava,
which is not related to cardiac tamponade. Murmurs are due to valvular disease. Absent
breath sounds are pulmonary problems. A displaced apical pulse is usually a result of
hypertrophy of the heart. S3 gallop is a classic sign of heart failure.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2
Osborn, et al., Test Item File for Medical-Surgical Nursing:
Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
Full file at http://testbank360.eu/test-bank-medical-surgical-nursing-1st-osborn
7. The priority NANDA for a hemorrhaging client in the emergency department would
be:
1. Ineffective tissue perfusion related to hypovolemia.
2. Impaired ventilation related to airway obstruction.
3. Fluid-volume deficit related to decreased renal perfusion.
4. Ineffective breathing related to shallow respirations.
Correct Answer: Ineffective tissue perfusion related to hypovolemia.
Rationale: When a client is hemorrhaging, the tissues are not being perfused. Therefore,
major organs such as the heart, brain, and lungs will receive oxygenation, and other
organs such as kidneys, intestines, and long muscles will not receive oxygenation and
will become ischemic. Hemorrhaging relates to arterial and venous perfusion and does
not impact ventilation. The airway is not obstructed, and unless the bleeding is in the lung
tissues (which is not mentioned in this question), breathing will not be impaired initially;
therefore, this would not be a priority NANDA. The hemorrhaging person is losing
volume, but it is due to the injury and actual blood loss rather than renal perfusion.
Cognitive Level: Analysis
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 3
Osborn, et al., Test Item File for Medical-Surgical Nursing:
Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
Full file at http://testbank360.eu/test-bank-medical-surgical-nursing-1st-osborn
8. If the trauma client was experiencing pain, the nurse may assess which of the
following objective data?
1. Facial grimacing and change in blood pressure or pulse
2. Flushed skin on neck and face, bradycardia
3. Hyperactive deep tendon reflexes and gripping hands
4. Increased anxiety and verbalizing “impending doom”
Correct Answer: Facial grimacing and change in blood pressure or pulse
Rationale: Facial grimacing and changes in breathing pattern, blood pressure, and pulse
along with diaphoresis and agitation are objective signs of pain. The patient will be in
tachycardia. With acute pain the deep tendon reflexes will not be affected. Patients with
pain have increased anxiety but usually do not verbalize “impending doom.” Patients
experiencing and internal hemorrhage or a cardiac abnormality many times verbalize
“impending doom” comments such as “I’m going to die.”
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3
Osborn, et al., Test Item File for Medical-Surgical Nursing:
Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
Full file at http://testbank360.eu/test-bank-medical-surgical-nursing-1st-osborn
9. When monitoring the trauma client’s nutritional status, which of the following data
would be priority to assess?
1. Daily weights and presence of bowel sounds
2. Fluid-volume intake and food allergies
3. Ability to feed self and types of odor in the room
4. Family ability to assist with feedings and last documented bowel movement
Correct Answer: Daily weights and presence of bowel sounds
Rationale: Assessment of daily weights, 24-hour caloric intake, and presence of bowel
sounds, nausea and vomiting, or flatus are the objective priority data the nurse should
assess with regard to nutritional status. Fluid volume is important but is usually very low
in caloric intake and mainly prescribed for fluid and electrolyte balance. The ability to
feed self may be assessing the client’s neurological and musculoskeletal status. If the
client requires rehabilitation, then family assistance may factor in at that point in the
client’s recovery.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3
Osborn, et al., Test Item File for Medical-Surgical Nursing:
Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
Full file at http://testbank360.eu/test-bank-medical-surgical-nursing-1st-osborn
10. The trauma client’s spinal cord must be protected from injury. Therefore, the nurse
should:
1. Apply a rigid cervical collar and logroll the client.
2. Keep the client on a backboard for the first 24 hours.
3. Keep the client supine until all diagnostic exams have been completed.
4. Keep the client flat and run a hand underneath to assess for posterior injuries.
Correct Answer: Apply a rigid cervical collar and logroll the client.
Rationale: For trauma clients, approximately 55% of spinal injuries occur in the cervical
region; therefore, a rigid cervical collar is a must to prevent further injury. Manual
stabilization of the spine is maintained while the client is turned using the logrolling
technique. All sources of bleeding must be ruled out, so the back of the patient must be
assessed. Diagnostic exams are done with lifting help to maintain a stable spine. A
backboard is removed shortly after the client arrives at the emergency department.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 4
Osborn, et al., Test Item File for Medical-Surgical Nursing:
Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
Full file at http://testbank360.eu/test-bank-medical-surgical-nursing-1st-osborn
11. Which of the following statements is accurate with regard to gerontological
consideration in trauma clients?
1. Older clients have an increased incidence of subdural hematomas since their
veins are more fragile and less elastic when compared to those of younger
clients.
2. Younger clients have a thorax that is less compliant and are at a greater risk
for developing rib fractures and flail chest.
3. Older clients have a greater capacity to increase their cardiac output on
demand, and therefore can tolerate greater blood loss than their younger peers.
4. Younger clients have an aorta that is closer to the surface and are at high risk
for tears if their abdomen is struck.
Correct Answer: Older clients have an increased incidence of subdural hematomas since
their veins are more fragile and less elastic when compared to those of younger clients.
Rationale: Older clients have an increased incidence of subdural hematoma because of
the increased dural vein fragility and loss of elasticity with age. The thorax of the older
client is less compliant and therefore more susceptible to injury. The elderly also are less
able to increase cardiac output on demand due to decreased compliance and a limited
degree of compensatory ability. The aorta of the elderly patient is inelastic and more
vulnerable to injury.
Cognitive Level: Analysis
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 4
Osborn, et al., Test Item File for Medical-Surgical Nursing:
Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
Full file at http://testbank360.eu/test-bank-medical-surgical-nursing-1st-osborn
12. Upon arrival at the trauma center, which of the following patients is least likely to
receive aggressive fluid resuscitation as an early intervention?
1. The patient with an open abdominal wound from a car accident
2. The patient whose hands were burned in a kitchen fire
3. The patient with a serious head injury from a fall
4. The patient whose leg was severed in an industrial accident
Correct Answer: The patient with an open abdominal wound from a car accident
Rationale: For a patient who is actively bleeding, increasing the arterial blood pressure
through administration of fluids can dislodge clots and interfere with the hemostatic
mechanisms that manage clotting. Current data suggest that aggressive fluid resuscitation
may be useful for patients with head injuries, thermal injuries, and isolated injury to an
extremity.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 4
Osborn, et al., Test Item File for Medical-Surgical Nursing:
Preparation for Practice Copyright 2010 by Pearson Education,
Inc.