Week 5 Complex Adult Health - Edapt Study Guide - Nursing Care: Trauma and Emergency (Module 1, Week 5) fully solved questions with 100% accurate solutions 2025-2026

What would be included in a primary survey of the emergency department?

Primary survey focuses on:

airway

alertness

breathing

circulation

catastrophic hemorrhage

disability

exposure/environmental control

What is the aim of the primary survey in the emergency department?

Primary survey aims to identify life-threatening conditions so that immediate interventions may be initiated. ​

What is a secondary survey in the ED?

Secondary survey begins after addressing primary needs and is a brief, systematic process that aims to identify all injuries.

History, head-to-toe assessment, and inspection of posterior and anterior surfaces are part of secondary survey. ​

LMNOP for remembering resuscitation aids and adjunct measures in ED?

It is essential to begin adjunct measures for monitoring the patient's condition. Use the mnemonic "LMNOP" to remember key resuscitation aids needed.​

L = laboratory testing​

M = monitor electrocardiogram (ECG) for heart rate and rhythm​ (initiate continuous cardiac monitoring)

N = nasogastric tube to decompress and empty the stomach reducing the risk for aspiration​

O = oxygenation and ventilation (continuous SaO2 monitor)​

P = pain assessment and management​

What should be done with the family of a patient receiving resuscitation or invasive procedures? Why?

The family should be allowed to be present during resuscitative and invasive procedures. It reduces patient anxiety and increases comfort as well as allows the patient advocate to be present.

When should care be transferred from the ED?

Care should not be transferred from the emergency department until the patient has been stabilized. ​

What are some considerations when dealing with a possible frontal skull fracture? What are some indications of a frontal skull fracture?

A dysconjugate gaze and raccoon eyes (periorbital bruising) may indicate a fracture at the base of the frontal part of the skull.

*Contraindication of NG Tube- with significant head or face trauma as the tube could enter the brain (orogastric tube is the alternative)

*Ears and nose should be inspected for clear fluid (cerebrospinal fluid), which should not be blocked from draining.

*Pharmacologic pain control is indicated as well as a CT scan to determine the extent of the injury.

What is triage?

Triage is the process of rapidly determining patient acuity and is one of the most important skills needed by an emergency nurse.​

Describe the Emergency Severity Index used in triage.

A triage system identifies and categorizes patients so that the most critically ill or injured are treated first. The Emergency Severity Index (ESI) uses a 5-level triage system that incorporates illness severity and resource use to determine who should be treated first.

ESI-1

ESI-2

ESI-3

ESI-4

ESI-5

What is ESI-1?

*Unstable client requires immediate life-saving intervention​

*High resource utilization​

For Example:

cardiac arrest, severe respiratory distress​, excessive bleeding

What is ESI-2?

*Client in high-risk situation with likely life-threatening injury must be seen within 10 minutes​

*High resource utilization​

For Example:

cardiac ischemia, unresponsive with multiple trauma

What is ESI-3?

*Stable client with unlikely but possible life-threatening injury should be seen with one hour​

*Medium to high resource utilization​

For Example:

abdominal pain, hip fracture

What is ESI-4?

*Stable client without life-threatening injuries whose care can be delayed​

*Low resource utilization​

For Example:

closed extremity trauma, laceration, cystitis

What is ESI-5?

*Stable client without life-threatening injuries whose care can be delayed​

*Low resource utilization​

For Example:

minor burn, flu symptoms

How would one approach using the Emergency Severity Index in triage?

First, assess the patient for life-threatening illness or injury. ​The triage system, also known emergency severity index, rates client status from life-threatening (ESI-1) to non-urgent (ESI-5).

Is the patient in imminent danger of dying? (ESI-1)​

Is this a high-risk patient who should not wait to be seen? (ESI-2)​

If the patient does not meet criteria for ESI-1 or ESI-2, evaluate for the number of anticipated resources needed.

Assign patients to ESI-3, ESI-4, and ESI-5 based on this determination.

*ESI-3 and above must have normal vital signs*

Choose the ESI.

A 28-year-old arrives to the emergency department stating, "I have been vomiting all night. I think I ate some bad shellfish." The client reports abdominal cramping with pain 4/10 and diarrhea but denies fever. ​

Vital Signs:

T 97.8ºF (36.6ºC)

HR 94

P 121/74

R 16

Client 1 is assigned an ESI level of_____?

ESI-5: The client is stable with normal vital signs. The client has no signs of cardiac or respiratory distress. Resource intensity is low, and the client likely needs examination only, no diagnostic studies or procedures. Care can be delayed.

Choose the ESI.

A 22-year-old arrives to the emergency department in severe respiratory distress stating, "I used my inhaler but it is not working".

She has a history of asthma. ​

Vital Signs:

T 98.6ºF (37ºC)

HR 125

BP 140/92

R 34

Client 2 is assigned an ESI level of _____?

ESI-1: The client is unstable with obvious life-threatening concerns (respiratory distress). Staff should be at the bedside continuously. Resource intensity is high. A team response is often needed. The client should be seen immediately.

Choose the ESI.

A 50-year-old construction worker arrives to the emergency department complaining of significant low back pain 8/10 and muscle spasms.

Vital Signs:

T 97.9ºF (36.6ºC)

HR 99

BP 135/82

R 20

Client 3 is assigned an ESI level of _____?

ESI-4: The client is stable with normal vital signs. The client has no signs of cardiac or respiratory distress. Resource intensity is low, but the client needs simple diagnostic procedures.

Choose the ESI.

A mother brings her 10-month-old infant to the emergency department reporting vomiting for 2 days. The infant appears lethargic and hypotonic. Anterior fontanelle is depressed.​Vital Signs:T 100.4ºF (38ºC)HR 165BP 72/40R 40Client 4 is assigned an ESI level of _____?

ESI-2: The client is in threatened condition with obvious concerns. The client requires continuous monitoring and frequent consultation. Resource intensity is high. The client needs multiple diagnostic studies and must be seen within 10 minutes.

What is the consideration if Hemorrhage is identified?

If uncontrolled hemorrhage, reprioritize to circulation (catastrophic hemorrhage), airway, breathing. Hemorrhage must be controlled first.

Primary Survey: Airway

Most trauma deaths occur due to airway obstruction, causing hypoxia.

Signs include dyspnea, gasping, inability to speak, agonal breaths, or face/neck trauma.

The patient's response to verbal and painful stimuli should be assessed.

Alertness level is essential to choosing an airway intervention.

Progress from least to most invasive --- opening airway with jaw thrust, suctioning, nasal or oral airway, then endotracheal intubation.

Emergency tracheotomy may be needed.

Primary Survey: Breathing

All critically ill or injured patients have increased metabolic and oxygen demand.

High-flow oxygen (100%) via non-rebreather mask is needed.

Treatment of the underlying cause is essential to improved outcomes. ​

Signs of altered breathing include dyspnea, paradoxical or asymmetric chest wall movement, decreased or absent breath sounds, visible chest wounds, cyanosis, tachycardia, or hypotension.

Common causes are fractured ribs, pneumothorax, penetrating injury, allergic reaction, pulmonary emboli, and asthma. ​

Primary Survey: Circulation

Adequate blood circulation is essential to prevent shock.

Monitor pulses, skin temperature and color, mental status, and capillary refill to identify early signs of shock. ​

Two large-bore intravenous (IV) catheters should be inserted in the upper extremities unless contraindicated due to fracture or injury.

Aggressive fluid resuscitation using isotonic solution is often needed.

If peripheral IV access is not possible, consider intraosseous or central line placement as soon as possible.

If packed red blood cells are needed emergently, give O-negative transfusions. ​

Primary Survey: Disability

The patient's level of consciousness determines the degree of disability.

Use the Glasgow Coma Scale (GCS). Pupillary response is another needed assessment.

Important! GCS is not accurate for intubated or aphasic patients. ​

Primary Survey: Exposure and Environmental Control

Clothing must be removed to perform a thorough assessment.

When removing or cutting away clothing, be sure to preserve any forensic evidence. ​

DO NOT remove impaled objects!​

Use warming blankets, overhead warmers, and warmed intravenous fluids to limit heat loss and prevent hypothermia.​

Primary Survey: Facilitate Adjuncts and Family

Family presence during resuscitation and invasive procedures is evidence-based.

Caregivers provide comfort and serve as advocates.

A member of the interprofessional team should be assigned to provide information to the family at regular intervals.

Primary Survey: Get Resuscitation Adjuncts

Start adjunct measures for monitoring the patient's condition and response to treatment as soon as possible.

L = Laboratory tests​

M = Monitor ECG for heart rhythm and rate​

N = Nasogastric tube to empty the stomach and prevent aspiration​

O = Oxygenation and ventilation assessment with continuous pulse oximetry monitoring​

P = Pain assessment and management

What is Rapid Sequence Intubation?

Rapid sequence intubation (RSI) is used to secure an unprotected airway in an emergency.

It requires sedatives and paralytic medications to reduce the risk of aspiration and airway trauma.

What are the 7 Ps guiding the pre and post steps of rapid sequence intubation?

Preparation

Pre-oxygenation

Pre-treatment

Paralysis and Induction

Protection and Positioning

Placement with Proof

Post-Intubation

When does the secondary survey begin?

After addressing the primary survey and starting any necessary life-saving interventions.

What does the secondary survey aim to identify?

This brief, systematic process aims to identify all injuries and includes history, head-to-toe assessment, and inspection of posterior surfaces.

What is included in the HISTORY of a secondary survey?

SAMPLE:

Symptoms associated with illness

Allergies and tetanus status

Medication history

Past health history

Last meal

Events leading up to illness

What is included in the Head to Toe Assessment of the secondary survey?

Head, neck, face- Eye movements, Battle's sign, periorbital bruising

Chest- inspection, palpation for heart and lung injuries

Penetrating trauma- DO NOT REMOVE impaled object

Blunt trauma- focused abd sonography for trauma and CT scan

Pelvis perineum- pelvic fracture, bladder distention, hematuria, dysuria, inability to void

Extremities- tenderness, crepitus, deformities, pulses, compartment syndrome

Posterior surfaces inspection

Ongoing evaluation- airway, breathing, LOC, VS, pulses, skin temp and color

Discuss therapeutic hypothermia.

Patients with nontraumatic, prehospital cardiac arrest may benefit from therapeutic hypothermia. Therapeutic hypothermia, most often referred to as targeted temperature management (TTM), may be used for at least 24 hours after the return of spontaneous circulation. It can decrease mortality rates and improve neurologic outcomes in many patients. ​

The TTM induction phase begins in the emergency department.

The goal is a core temperature of 89.6º - 96.8ºF (32º - 36ºC). Various methods are used to cool the patient, including cold saline infusions and surface cooling devices. TTM requires intubation, mechanical ventilation, invasive monitoring, and continuous assessment.

When does heat stress occur?

When thermoregulatory mechanisms (sweating, vasodilation, increased respirations) cannot compensate for exposure to increased ambient temperatures, heat stress occurs.

Who is at the highest risk for heat stress emergencies?

Young children, older adults

What are the risk factors for heat stress emergencies?

-young age, older age

-strenuous activity in hot environments

-clothing that interferes with perspiration

-high fever

-preexisting illness (CV, resp., DM, CNS compromise)

What are the 3 types of heat-related emergencies?

Heat cramps

Heat exhaustion

Heatstroke

What are the treatment goals for heat-related emergencies?

Reduce core temperature

Manage airway and circulation

Monitor for dysrhythmias

Fluid and electrolyte imbalance correction

What are some cooling methods for heat-related emergencies?

Evaporative cooling

Conductive cooling

Ice packs to groin and axillae

Peritoneal or rectal lavage with iced fluids

How is shivering related to heat emergencies?

Control shivering. Shivering increases core temperature due to heat generation by muscle activity. Monitor for AKI due to rhabdomyolysis.

Discuss: Cold Injuries

Cold injuries can be localized (frostbite) or systemic (hypothermia).

Age, duration of exposure, environmental temperature, preexisting conditions, medications that suppress shivering, and alcohol intoxication are contributing factors.

Nicotine causes vasoconstriction, so smokers are more at risk for cold-related injury.

What is frostbite?

Frostbite is tissue freezing that results in peripheral vasoconstriction causing decreased in blood flow and vascular stasis. When temperature decreases, ice crystals form in the intracellular space, destroying the cells, which results in edema.

What are the stages of frostbite?

Normal

Frostnip

Superficial frostbite

Deep frostbite

Describe frostnip.

Mild frostbite that irritates the skin, causing redness and a cold feeling followed by numbness.

Describe superficial frostbite.

Superficial frostbite involves the skin and subcutaneous tissue, usually the ears, nose, fingers, and toes.

-Appearance is waxy pale yellow to blue to mottled​

skin feels "crunchy" and frozen​.

-Patient reports numbness, tingling, or burning sensation​.

Tissue is easily damaged. Avoid squeezing, massaging, or scrubbing the injured area. Swelling will occur with thawing, so remove clothing and jewelry to avoid constriction. ​

Immerse in circulating water at 98.6ºF - 104ºF (37ºC - 40ºC).

Use warm soaks for the face. Blisters form within a few hours of thawing and must be debrided and covered with a sterile dressing. ​

Rewarming is extremely painful, so analgesia is essential. Tetanus prophylaxis may be necessary as well.

Describe deep frostbite.

Deep frostbite involves muscle, bone, and tendon. ​

Appearance is white. Mottling gradually progress to gangrene.​

Skin is insensitive to touch​.

Immerse in circulating water at 98.6ºF - 104ºF (37ºC - 40ºC) until flushing occurs distal to the injured area. After rewarming, elevate the extremity to reduce edema, which begins within 3 hours.

Blisters form within hours to days. ​

Rewarming is painful. Analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) are used for pain management and anti-inflammatory effects.

Tetanus prophylaxis is necessary as well as evaluation for systemic hypothermia.

What is hypothermia?

Hypothermia is a core temperature below 95ºF (35ºC) and occurs when heat produced by the body cannot compensate for heat lost to the environment. Peripheral vasoconstriction is the body's first attempt to conserve heat, followed by shivering to produce heat. ​

What are the stages of hypothermia?

Hypothermia can be mild, moderate, or severe.

Mild hypothermia

*Temps between 93º - 95ºF (33.9º - 35ºC). Symptoms include shivering, lethargy, confusion, and minor heart rate changes.​

Moderate hypothermia

*Moderate hypothermia is a temperature between 86º - 93ºF (30º - 33.9ºC). Symptoms include rigidity, bradycardia, bradypnea, severe hypotension, metabolic and respiratory acidosis, and hypovolemia. Atrial and ventricular dysrhythmias develop. Blood flow to the kidneys is decreased, which impairs water reabsorption and leads to dehydration. Hematocrit increases as intravascular volume decreases. As cold blood becomes thicker, the patient is at risk for thrombus formation. ​

Severe hypothermia

*Severe hypothermia is a temperature below 86ºF (30ºC). Shivering stops and results in a potentially life-threatening situation. Metabolic rate, heart rate, and respirations slow dramatically. Reflexes are absent. Pupils are fixed and dilated. Ventricular fibrillation or pulseless electrical activity may be present.

Attempt to warm the patient to at least 86ºF (30ºC) before pronouncing death.

What are the four ways the body loses heat?

Radiation

Conduction

Convection

Evaporation

What are the 3 methods of rewarming?

Passive rewarming- remove wet clothes, apply dry warm blankets, radiant lights, keep head covered. Warm the trunk first.

Active external rewarming- apply heating devices, use warm water submersion.

Active internal rewarming- administer warmed IV fluids and heated O2. Periotneal and rectal lavage. Extracorporeal circulation (dialysis, rapid fluid infuser, cardiopulmonary bypass)

What are some expected manifestations of hypothermia?

Shivering

Kussmaul respirations

Bradypnea

Hematocrit 55%

Lethargy

Pupils?

What is a submersion injury?

Occurs when a person is hypoxic from submersion in liquid, usually water.

Submersion injury occurs when a patient is hypoxic from submersion in liquid, usually water. Approximately 3,500 fatal unintentional drownings occur annually in the United States (CDC, 2020) . Many are children younger than 14 years (CDC, 2020).

As water is aspirated, the osmotic gradient causes fluid imbalance in the body.​

Hypotonic fresh water is absorbed into the bloodstream through the alveoli, which causes the breakdown of surfactant and pulmonary edema.​

Hypertonic saltwater draws fluid from the circulatory system, impairing alveolar gas exchange causing hypoxia. The body compensates by shunting blood to the lungs depriving other organs of oxygen. This results in cerebral injury, edema, and brain death. ​

What happens with submersion in cold water?

Submersion in cold water (less than 32ºF [0ºC]) may slow the progression of hypoxic brain injury. Aggressive resuscitation efforts in the prehospital phase improve survival outcomes. ​

How is a submersion injury treated?

Treatment is focused on correcting hypoxia and fluid imbalances while supporting physiologic function. Rewarming may be necessary is hypothermia is present. ​

What is penetrating trauma?

Penetrating trauma occurs when an object pierces the skin and enters the body creating an open wound.

If the object passes through the body completely, it is called a perforating injury. The most common of these types of injuries are gunshot and stab wounds.

The severity of the injury depends on the body part and location involved.

Penetrating head trauma has a high mortality rate. Those who survive likely have permanent neurologic deficits. ​

Penetrating neck trauma poses a significant risk for hemorrhage and spinal cord injury.​

Penetrating abdominal trauma severity depends on the organs injured. ​

Extremity trauma can cause permanent disability due to hemorrhage. Angulated fractures can cause penetrating trauma.

What kind of medical approach gives the patient with a traumatic injury the best chance at recovery?

An organized team approach in the first hour after a traumatic injury saves lives.

When assessments are prioritized and appropriate interventions are implemented, the patient has the best chance for survival and full recovery. ​

What are the indicators of adequate resuscitations?

-hemodynamic and renal parameters are within normal limits​

-core body temperature normal​

-serum lactate less than 2 mmol/L​

-no base deficit​

-arterial pH 7.35 to 7.45​

-hemoglobin greater than 9 g/dL​

-serum calcium within normal limits​

-serum potassium within normal limits​

-coagulation profile within normal limits​

-pain managed

What are some examples of Internal and External emergencies that a hospital might deal with?

Internal Emergencies​:

-loss of power

-fire

-severe facility damage from tornado or hurricane​

External Emergencies​:

-biologic (bioterrorism)​

-chemical ​

-hazardous​

-radiologic (radiation)​

-explosive

What is a mass casualty incident?

A mass casualty incident (MCI) is a catastrophic event that overwhelms local resources, and typically, involves large numbers of victims.

Resources from outside the affected community are often necessary to handle the crisis.

How is victim triage handled in a MCI?

Victim triage must be handled efficiently and quickly.

Colored tags are often used to designate both the seriousness of the injury and the chance for survival.

How does the victim tagging system for an MCI work?

Red: Life-threatening

Yellow: Urgent

Green: Minor Injuries

Black: Expectant/Deceased