A patient is admitted with trauma to the integumentary system. Which type of skin trauma should the ...

The answer to question 1

Correct Answer: 2, 3, 4

Abrasions, or partial-thickness denudations of an area of integument, generally result from falls or scrapes. Lacerations are open wounds that result from sharp cutting or tearing. Contusions, or superficial tissue injuries, result from blunt trauma that causes the breakage of small blood vessels and bleeding into the surrounding tissue. Cutaneous is a term used to refer to the integument, not to trauma to the skin. A keloid is a type of scar.

The answer to question 2

Correct Answer: 3, 4, 5

The Champion Revised Scoring System analyzes three elements: the Glasgow Coma Scale, systolic blood pressure, and respiratory rate. The patient receives a total score; the highest score is 12. Although the diastolic blood pressure and heart rate are part of the patient's assessment, they are not included in the Champion Revised Scoring System.

The answer to question 3

Correct Answer: 3
In compensatory shock, the blood loss is 750 mL, with up to 15 blood volume loss. Other indicators are normal or increased; the patient is only slightly anxious. In early reversible shock there is a blood loss of 7501500 mL, 1530 blood volume loss, heart rate >100, blood pressure normal, pulse pressure decreased, capillary refill and respiratory rate slightly increased, urine output 2030 mL/h. The patient is mildly anxious to agitated. The manifestations in progressive shock are: blood loss of 15002000 mL, 3040 blood volume loss, heart rate >120, blood pressure and pulse pressure decreased, capillary refill increased over normal, moderate tachypnea, urinary output below normal, and mental status altered. In refractory shock, the patient's condition has deteriorated markedly, with over 2,000 mL blood loss and >40 loss of blood volume.

The answer to question 4

Correct Answer: 1

Interventions appropriate for the problem of anxiety include reducing stimuli, which is calming and facilitates rest, and medicating for pain because pain precipitates or aggravates anxiety. Assessing blood pressure and heart rate would be appropriate for a problem with cardiac output. Monitoring central venous pressure would be appropriate for a problem with tissue perfusion. Assessing bowel sounds would be appropriate for a problem with cardiac output.

The answer to question 5

Correct Answer: 1
Posttraumatic stress disorder is an intense, sustained emotional response to a disastrous event. It is characterized by emotions that range from anger to fear, and by flashbacks or psychic numbing. In the initial stage, the patient can be calm or might express feelings of anger, disbelief, terror, and shock. In the long-term phase, which begins anywhere from a few days to several months after the event, the patient often experiences flashbacks and nightmares of the traumatic event. The patient also might call on ineffective coping mechanisms, such as alcohol or drugs, and withdraw from relationships.

The answer to question 6

Correct Answer: 1
Jugular vein distention is seen in cardiogenic shock. Warm extremities are seen in early septic shock and anaphylactic shock. Laryngospasm and urticaria are seen in anaphylactic shock.

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