Initial Assessment Flashcards

During the primary survey, which component of the 'E' step in the ABCDE mnemonic is assessed?

Answer: Exposure and environmental control

The 'E' in the primary survey stands for Exposure and Environmental Control — removing clothing to expose injuries while preventing hypothermia.

A trauma patient's GCS is assessed as: eyes open to pain (2), confused verbal response (4), withdraws to pain (4). What is the total GCS score?

Answer: 10

GCS = Eye (2) + Verbal (4) + Motor (4) = 10, indicating moderate traumatic brain injury.

Which intervention is the priority when a tension pneumothorax is identified during the primary survey?

Answer: Needle decompression at the 2nd intercostal space, midclavicular line

Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression without waiting for imaging.

The 'D' in the ABCDE primary survey specifically refers to:

Answer: Disability: neurological status

Disability in the primary survey refers to a rapid neurological assessment including GCS, pupils, and gross motor function.

During secondary survey, a trauma patient reports pain rated 8/10. Which action is most appropriate for the trauma nurse?

Answer: Administer pain medication per protocol while continuing the assessment

Pain management should not be withheld during assessment; analgesics can be given per protocol while the secondary survey continues.

A FAST exam (Focused Assessment with Sonography in Trauma) is primarily used to detect:

Answer: Free fluid (blood) in the peritoneal and pericardial spaces

FAST is a bedside ultrasound exam used to rapidly identify free fluid (hemorrhage) in the abdomen and around the heart.

Which finding during the initial assessment most strongly suggests cardiac tamponade?

Answer: Hypotension, distended neck veins, and muffled heart sounds (Beck's triad)

Beck's triad — hypotension, jugular venous distension, and muffled heart sounds — is the classic presentation of cardiac tamponade.