CASE STUDY 13 Head and Leg Trauma and Shock
Ms. A is a 20-year-old college student who had been drinking at a fraternity party before she fell from a
... [Show More] second-floor balcony. Paramedics were called by one of the more sober students at the party, and Ms. A has just arrived in the emergency department (ED). A fellow college student who accompanies Ms. A tells you, “She was completely knocked out right after the fall. But then she woke up a little, so we thought she was okay—until she stopped moving again.”
You are assigned as the ED triage nurse. When you assess Ms. A, there is no response to commands or to having her name called. She extends her arms and legs stiffly when nail bed pressure is applied, but there is still no verbal response. Her eyes are shut, and she does not open them even with the nail bed pressure. When you open her eyelids, you see that her pupils are unequal, with the right pupil larger than the left. The pupil response when you shine a flashlight into her eyes is sluggish.
Ms. A's blood pressure is 70/30 mm Hg, she is in a sinus bradycardia with a rate of 40 beats/min, and her respiratory rate is 6 breaths/min. Her respirations are irregular, and she has 20-second periods of apnea. You note that she has a large occipital laceration and that her left leg is misaligned.
The paramedics have a cervical collar and backboard in place. A 16-gauge catheter has been inserted at the left antecubital area and lactated Ringer solution is infusing at 150 mL/hr.
1. Which additional assessment information is most important to obtain at this time?
1. Temperature
2. Breath sounds
3. Pedal pulses
4. Oxygen saturation
2. Which is the best way to clearly document Ms. A's level of consciousness (LOC)?
1. Client has a decreased LOC.
2. Client is unresponsive.
3. Client GCS score = 4.
4. Client is comatose.
3. When describing Ms. A's neurologic assessment, you will chart “Client demonstrates __________________ posturing in response to nail bed pressure.”
4. Based on Ms. A's vital signs, she appears to be in shock. Which types of shock are you most concerned about for this client? (Select all that apply.)
1. Cardiogenic
2. Hypovolemic
3. Neurogenic
4. Septic
5. Anaphylactic
5. You are working with Dr. G, a new medical resident whose first day in the ED rotation is today. Which action by Dr. G indicates that you need to consult quickly with the supervising physician?
1. Dr. G assesses for the Babinski sign.
2. Dr. G increases the intravenous (IV) infusion rate to 200 mL/hr.
3. Dr. G orders an electrocardiogram taken at once (stat).
4. Dr. G prepares to perform a lumbar puncture. [Show Less]