Alexanders Care of the Patient in Surgery 15th Edition Rothrock Test Bank
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Chapter 28: Trauma Surgery
- Traumatic deaths may occur in three phases or time frames. Which phase occurs within the first 1 to 2 hours after the injury, where definitive trauma care has the most significant effect?
The second phase occurs within the first 1 to 2 hours after the injury. These patients have injuries to the spleen, liver, lung, or other organs that result in significant blood loss. This is the group in which definitive trauma care (i.e., appropriate and aggressive resuscitation with adequate volume replacement) may have the most significant effect (the golden hour).
REF: p. 1104
- Which statement regarding level I and level II trauma centers (TCs) best describes the difference between the two types of centers?
|a.||A level I TC is staffed 24 hours/7 days, while a level II has many support services that are open and staffed 8 hours/5 days.|
|b.||A level I TC has a transplant program, while a level II is only able to complete organ procurements.|
|c.||A level I TC provides care for every type of injury, while a level II lacks some specialized resources.|
|d.||A level I TC requires trauma certification and 8 hours of annual trauma education for all staff, while a level II does not.|
TCs are classified based on the scope of available services and resources. A level I TC is capable of providing total care for every type of injury. Accepting this designation commits the TC to providing qualified personnel and equipment necessary for rapid diagnosis and treatment on a 24-hour basis. A level II TC provides comprehensive care for all injuries but lacks some of the specialized clinicians and resources required for the level I designation. A level II facility may provide surgical intervention if the critical nature of the injury dictates immediate intervention before transfer to a level I facility.
REF: p. 1104
- Which statement regarding level III and level IV TCs best describes the difference between the two types of centers?
|a.||A level III TC provides advanced cardiac life support (ACLS), surgery, stabilization, and transfer, while a level IV only provides ACLS services before immediate transfer to a higher level center.|
|b.||A level III TC immediately transfers to a higher level center, while a level IV does not accept trauma patients.|
|c.||A level III TC determines severity of injury and provides ACLS support before transfer to a level IV center, while a level IV provides all comprehensive services.|
|d.||A level III TC provides all types of trauma services but is located in a rural setting, while a level IV provides post-hospital convalescent care for trauma patients.|
A level III facility provides prompt evaluation, resuscitation, emergency surgery, and stabilization, as needed, before transfer to a higher-level facility. The American College of Surgeons (ACS) recommends that in level II and III centers, an operating room (OR) team be readily available at all times. Depending on the population served and the volume of urgent cases, this requirement may be met with on-call staff. A level IV TC has the ability to provide advanced trauma life support before patient transfer.
REF: p. 1104
- Mechanism of injury (MOI), or kinematics, involves the action of forces on the human body and their effects. Motor vehicle collisions (MVCs) account for a high degree of blunt trauma. In the case of an adult trauma victim who is the driver in a head-on MVC at high speed, where the head hits the windshield and the chest impacts the steering wheel, what is the MOI and description of the possible injuries?
|a.||Acceleration; contusion of the occipital lobe of the brain and posterior chest wall|
|b.||Deceleration; contusion of the frontal lobe of the brain and anterior chest wall|
|c.||Acceleration/deceleration; injury to the anterior and posterior brain and internal thoracic organs and vessels|
|d.||Blast force trauma; impact force causes subdural and epidural hemorrhage and transaction of the thoracic aorta and great vessels|
During an MVC, actually three collisions occur. The first collision is that of a car into another object. The second collision is the impact of the occupant’s body on the vehicle’s interior. The third collision occurs when an internal body structure hits a rigid bony surface. A coup-contrecoup injury of the brain, for example, is the result of an acceleration force to one area of the brain and a deceleration force to an opposite area. The blunt trauma injury results from a combination of forces, such as acceleration and deceleration, and may not result in a break of the skin.
REF: pp. 1106-1107
- An adult man was the victim of a low-velocity, low-caliber gunshot wound to the anterior left quadrant of the lower abdomen. The gun was shot at far range. What is the trajectory of the gunshot?
|a.||Small entrance wound with blast injury to the left sigmoid colon and large exit wound|
|b.||Large entrance wound with complete transection of the left colon and no exit wound|
|c.||Large entrance wound with possible injury to left quadrant vessels and contusion of anterior sigmoid colon|
|d.||Small entrance wound with no exit wound; energy is dissipated to the tissues|
Penetrating trauma is a result of the passage of a foreign object through tissue. The degree or extent of tissue injury is a function of the energy that is dissipated to the tissue and the surrounding areas. The anatomic structures most often injured include the liver, intestines, and vascular system. The extent of the injury relates to the nature of the foreign object (e.g., bullet caliber, knife size), distance from the weapon, structures penetrated, and amount of energy dissipated to the structures. Commonly the entrance wound is smaller than the exit wound because of the dissipation of energy, but an exit wound may not always be present.
REF: p. 1106
- When the patient arrives in the emergency department (ED), the trauma team initiates a primary assessment. This is a logical, orderly process of patient assessment for potential life threats. These assessment activities are based on established protocols for advanced trauma life support (ATLS). The mnemonic “ABCDE” is used, representing assessment of the following: airway, breathing, circulation, disability, and exposure. The D and E represent what degree of investigation?
|a.||D = musculoskeletal impairments; E = environmental issues|
|b.||D = a brief reflex examination; E = extraneous sensory impairments|
|c.||D = history of prior impairments; E = events that contributed to the injury|
|d.||D = a brief neurologic examination; E = exposure to reveal all life-threatening injuries|
The mnemonic “ABCDE” is used, representing assessment of the following: airway (with cervical spine precautions), breathing, circulation, disability (brief neurologic examination), exposure (to reveal all life-threatening injuries, including environmental control [thermoregulation]).
REF: p. 1107
- Trauma patients often arrive with cervical collars in place, or collars are placed the ED team if cervical spine is suspected. What event needs to take place before the team removes the cervical collar and continues care?
|a.||A halo traction apparatus is applied.|
|b.||A cervical radiograph is obtained to rule out injury to the neck.|
|c.||A computed tomography (CT) scan with contrast of the upper body is obtained to rule out vascular involvement.|
|d.||A myelogram of the cervical spinal canal is obtained to rule out injury to the spinal cord.|
A trauma team member can stabilize the head and neck, if necessary, until a cervical collar is placed. Once placed, the team does not remove it until an examination and cervical radiograph confirms there is no neck injury.
REF: p. 1108
- The extent of injury after blunt trauma may be difficult to determine. What noninvasive diagnostic test is critical to diagnosis in potential traumatic brain injury?
|a.||Pupil reflex and response to light|
|c.||CT scan of the head|
If the resources are available, the TC protocol may also include a CT scan as a diagnostic or screening tool. Depending on the MOI, such as a fall, CT scans of the head and abdomen may be performed. Because injuries in blunt trauma are very difficult to diagnose, the CT scan is frequently done before patient transfer to the OR. A high index of suspicion is maintained for other injuries until proven otherwise. Bowel injuries may be missed during initial scanning. A CT scan of the brain revealing an injury incompatible with life may alter the course of definitive treatment for a patient.
REF: p. 1110
- Focused assessment with sonography in trauma (FAST) may assist with diagnosis in difficult situations. Which group of scans is performed, and what do they identify?
|a.||Chest, pelvic, and four abdominal scans; collections of fluid and free air|
|b.||Chest, abdominal, and cervical spine scans; hemorrhage|
|c.||A full body scan; midline shifts|
|d.||Upper and lower extremity scans; compartment syndrome|
FAST is a portable, noninvasive scan that can be used to determine the presence of free fluid in the chest or abdomen. The typical FAST scan consists of chest, pelvic, and four abdominal scans. The chest scan examines right and left chest views and can determine the presence of pericardial fluid. The upper right abdominal scan evaluates the hepatorenal area, the first area that shows the presence of air. The left upper scan examines the splenorenal area. The left and right paracolic gutters are also scanned. The pelvic scan assesses for free fluid near the bladder.
REF: p. 1110
- The perioperative nurse may not be able to assess the trauma patient until the patient arrives in the OR for surgical intervention. If the patient’s condition permits, the perioperative nurse should obtain a brief, precise report from the ED nurse. One component of this report is the AMPLE history. What are the components of the AMPLE mnemonic?
|a.||Assessment, MOI, pulse, level of consciousness, electrolytes|
|b.||Available family, medical history, problem, language, environmental conditions of event|
|c.||Allergies, medications, past medical history, last meal, event leading to injury|
|d.||Additional diseases, mean arterial pressure, prior surgeries, labs, extraneous injuries|
This history is referred to as the AMPLE history and includes the following: allergies, medications, past medical history, last meal (and last menstrual period when appropriate), events or environment leading to the accident or injury.
REF: p. 1108
- What is the description of damage control surgery, and what conditions may be present?
|a.||Trauma surgery performed a nontrauma surgeon; lack of specialty training|
|b.||Surgery performed during ambulance or helicopter transfer; patient movement|
|c.||Surgery that puts emphasis on trauma impact instead of complete anatomy repair; intentional retained sponges|
|d.||Surgery performed in the ED; inadequate sterile technique|
Damage control surgery is a well-recognized surgical strategy that sacrifices complete, immediate repair to adequately address the physiologic impact of trauma and surgery. Damage control surgery is a series of operations performed to accomplish definitive repair of abdominal injuries with consideration of the patient’s physiologic tolerance. The focus is on control of hemorrhage and contamination to stop bleeding and control any intestinal, biliary, or urinary leak into the abdominal cavity. If counted soft goods are intentionally left in the patient (e.g., in a damage control procedure at a level II, III, or IV center before transfer to a level I facility), the number and type of soft goods left in the wound should be documented on the perioperative nursing record and communicated when there is a transfer in patient care. The operative dictation the surgeon should also verify the presence of retained soft goods, their type, and their number. This allows for accurate counts in subsequent procedures and prevents the potential for inadvertently retained soft goods.
REF: p. 1121
- Blunt force to the larynx can result in a fracture and impose immediate airway obstruction. These patients are at risk for a lost airway and may require immediate tracheotomy followed repair of the fracture when the fracture is unstable or displaced. It is also important to consider that a trauma patient is assumed to have a full stomach; thus these patients are at high risk for aspiration and resultant pneumonia. What is an appropriate nursing action in the event of a lost airway after anesthesia induction and before intubation?
|a.||Assist the anesthesia provider with securing the airway while applying cricoid pressure|
|b.||Assist the anesthesia provider inserting a nasogastric tube and connecting to suction|
|c.||Leave the room to get the emergency tracheostomy tray and trach tubes|
|d.||Increase the oxygen delivery and perform a head tilt–chin lift|
Under the direction of the anesthesia provider, the perioperative nurse applies cricoid pressure. This pressure is maintained over the cricoid area until the cuff on the endotracheal (ET) tube is inflated and tube placement verified the anesthesia provider.
REF: p. 1116
- Mandibular fractures are highly associated with assault as the MOI. The goals of operative intervention are to reduce and immobilize the fracture, prevent infection, and restore facial cosmesis and function. What might be an appropriate nursing action and a nursing outcome statement for a patient with a mandibular fracture caused assault?
|a.||Give 100% oxygen; the patient will have the ability to verbalize concerns and ask questions|
|b.||Provide support and explain interventions; the patient will have fear-related behaviors|
|c.||Provide caring behaviors and offer comfort to allay fear and anxiety; the patient will not experience aspiration|
|d.||Provide orientation to surroundings; the patient and family will experience decreasing anxiety and fear|
The patient and family will experience decreasing anxiety and fear, as evidenced orientation to surroundings, ability to verbalize concerns and ask questions of the healthcare team, decreased fear-related behaviors (e.g., crying, agitation), and use of effective coping skills.
REF: p. 1112
- Trauma to the chest area is the primary cause of death in approximately 25% of trauma victims. Involvement of the heart, great vessels, lungs, and diaphragm, attributable to penetrating or blunt injury, can provide multiple unexpected findings when the chest is opened. Because of the nature of the potential findings and expected surgical intervention, what would be an appropriate preparatory nursing action?
|a.||Set up the autotransfusion system and resuscitation equipment|
|b.||Prepare the rapid response team and chaplain to be on alert|
|c.||Call for the small fragment set for rib fracture fixation at closure|
|d.||Prep the patient from the xiphoid to mid-thigh|
Autologous blood salvage units should also be considered during patient care preparation because blood salvage will be done if not contraindicated the nature of the injury. Because of the unexpected nature of trauma, planning perioperative care is of the utmost importance. Equipment, instruments, and supplies that have a high probability of use must be immediately available. When the trauma patient is transferred to the OR, the extent of injury is not always known.
REF: p. 1112
- A trauma patient is rushed to the OR after a primary survey is completed in the ED. He is a 36-year-old man with multiple penetrating gunshot wounds to the abdomen. He is bleeding profusely. What appropriate nursing actions are critical in the rapid preparation for this procedure?
|a.||Set up the autotransfusion system.|
|b.||Prep the patient from the suprasternal notch to the mid-thigh|
|c.||Place the aortic cross-clamp on the Mayo stand|
|d.||Open a silo-bag closure system on the sterile field|
The perioperative nurse should prep the patient from the suprasternal notch to the mid-thigh. This allows for rapid access to the chest to clamp the aorta should massive hemorrhage control be indicated; it also allows for exposure of the femoral arteries for potential cannulation and access to the thigh for harvesting a saphenous vein. If the abdomen is difficult to close, alternative wound closure techniques may be used to prevent the occurrence of abdominal compartment syndrome. One such method is to use a silo-bag closure, in which heavy plastic is trimmed to fit and sutured to skin edges.
REF: p. 1115
- A 26-year-old woman is rushed to the OR after a primary and secondary survey in the ED. She was hit a small truck as she was riding her bicycle through a busy intersection. She has sustained rib fractures and several fractured transverse vertebral processes. Renal injury is suspected. As the perioperative nurse prepares to insert a urinary catheter, she notices blood at the urinary meatus. What should the nurse’s next action be?
|a.||Place a gauze dressing over the perineum after inserting the urinary catheter|
|b.||Insert the catheter and notify the surgeon|
|c.||Discontinue the catheter insertion|
|d.||Insert a latex-free straight catheter to empty the bladder and then remove it|
In these instances an indwelling urethral catheter should not be inserted. Laceration of the kidney is closely associated with fracture of the ribs and transverse vertebral processes. This injury is detected the presence of blood at the urinary meatus. Blood at the urinary meatus may indicate a tear in the anterior urethra.
REF: pp. 1127-1128
- If an injury to a patient is a result of a violent crime, the team must give special attention to preservation of evidence during the course of patient care. When clothing is removed from the patient, why must it be placed and secured in a paper bag rather than a plastic bag?
|a.||Plastic bags may trap moisture and allow mold growth, destroying evidence.|
|b.||It is easier to write identifying information on paper rather than plastic.|
|c.||Plastic bags trap air, which could kill anaerobic microorganisms needed as evidence.|
|d.||Paper bags are more secure as they cannot be untied and retied.|
Clothing is placed in paper bags, labeled appropriately, and given to law enforcement personnel. Plastic bags trap moisture and may facilitate growth of mold, which could destroy evidence. The transport vehicle sheet should also be handled in a similar manner, since evidence may be present.
REF: p. 1115
- A 7-year-old girl fell off of a swing at school and landed on her head. She is not conscious. On the baseline neurologic exam, her Glascow Coma Scale (GCS) is 5. What is the recommended immediate treatment of choice?
|a.||Reassess with the modified GCS for children|
|b.||Phenytoin 15-20 mg/kg IV|
|c.||Monitor for hypotension and drug interactions|
|d.||Intubate with controlled ventilation|
For patients with a score of 8 or less, intubation with controlled ventilation is the immediate treatment of choice. In the highly combative patient, intubation may also be performed to allow adequate assessment of the extent of injury.
REF: p. 1122
- A 19-year-old woman is admitted to the OR for elevation of a depressed skull fracture without evidence of a hematoma. She has a history of seizure disorder and is at risk for increased cerebral pressure (ICP). The anesthesia provider administers a loading dose of medication to use for induction and another medication to decrease ICP under anesthesia. Select the appropriate induction and ICP-lowering medications.
|a.||Phenobarbital; midazolam (Versed)|
|b.||Fentanyl (Sublimaze); decadron|
|c.||Etomidate (Amidate); mannitol (Osmitrol)|
|d.||Propofol (Diprivan); furosemide (Lasix)|
Etomidate (Amidate) is the most commonly used induction agent. It acts in about 1 minute and lasts about 5 minutes and is often used in trauma patients, because it does not cause an increase in ICP or worsening of hypotension. An osmotic diuretic such as mannitol has proven to be beneficial in lowering ICP without reducing cerebral blood flow.
REF: p. 1116
- With injury to the brain, swelling may occur quickly, requiring aggressive decisions to manage increasing ICP. What is an appropriate diuretic medication to give, and what nursing actions would be indicated for an older adult patient with traumatic brain injury, increased ICP, and a history of congestive heart failure (CHF)?
|a.||Mannitol (Osmitrol) 1.5/kg IV; monitor cardiovascular status|
|b.||Furosemide (Lasix) 20-40 mg IV; monitor for hypotension and note extent of diuresis|
|c.||Mannitol (Osmitrol) 1.5/kg IV; monitor cardiovascular status; and furosemide (Lasix) 20-80 mg IV; monitor for hypotension and note extent of diuresis|
|d.||Neither mannitol (Osmitrol) 1.5/kg IV; monitor cardiovascular status; nor furosemide (Lasix) 20-80 mg IV; monitor for hypotension and note extent of diuresis|
Furosemide (Lasix): Adult dose 20-40 mg IV is the appropriate diuretic medication for managing ICP, because furosemide lowers ICP and blood pressure (BP). Adverse reactions of mannitol (Osmitrol) include pulmonary edema and CHF.
REF: p. 1114
- What special consideration should be made when assessing geriatric trauma patients before surgery?
|a.||They may have preexisting diseases and conditions.|
|b.||They commonly have diminished mental capacity and will have difficulty understanding the information provided.|
|c.||They have increased physiologic reserves.|
|d.||The Glascow Coma Scale cannot be applied if the patient has dementia.|
Preexisting medical conditions, medication use, decreased physiologic reserves, and the physical and psychologic stress experienced during surgical interventions place elderly trauma victims at increased risk for perioperative complications. The physiologic effects of aging combined with the preinjury health status of many elderly patients significantly affect their ability to respond to initial treatment for traumatic injuries and subsequent surgical intervention.
REF: p. 1118
- Autotransfusion can present a vital asset in trauma care when considering the high blood loss associated with many traumatic injuries. This process provides immediate volume replacement, decreases the amount of bank blood used, and reduces the possibility of transfusion reactions or risk of transfusion with bloodborne pathogens. What are the contraindications to using autotransfusion as a blood replacement source?
|a.||Clean, hemodiluted blood|
|b.||Blood contaminated with food, bowel contents, or antibiotic irrigation|
|c.||Blood and fluids squeezed out of sterile bloody sponges|
|d.||Pooled blood from a torn aorta|
The blood collected in the salvage unit must be free from contamination. If the abdomen is contaminated with free food particles or colonic perforation is present, the blood cannot be used. Similarly, once antibiotic irrigation is initiated, the blood salvage unit is not used. During autologous blood salvage the surgical technologist squeezes out additional blood and fluid from saturated sponges before discarding them from the surgical field.
REF: p. 1115
- The emergency medical services system consists of trained prehospital personnel who arrive at the scene and perform definitive interventions designed to reduce morbidity and mortality. What is the primary role of the prehospital personnel? (Select all that apply.)
|a.||Scoop and run to the nearest hospital ED while performing ABCs|
|b.||Deliver the victim to the hospital before the end of the golden hour|
|c.||Determine the severity of injury and initiate medical treatment|
|d.||Identify the most appropriate facility to which to transport the victim|
ANS: C, D
The golden hour starts at the scene, where prehospital personnel determine the severity of injury, initiate medical treatment, and identify the most appropriate facility to which to transport the patient.
REF: p. 1104