By J. Thorald. Sarah Lawrence College. 2019.
Explaining Mood Disorders Mood disorders are known to be at least in part genetic buy avanafil 50mg mastercard, because they are heritable purchase avanafil 100 mg otc. Serotonin best avanafil 200 mg, dopamine generic avanafil 50mg with visa, and norepinephrine are all known to influence mood (Sher &  Mann, 2003), and drugs that influence the actions of these chemicals are often used to treat mood disorders. The brains of those with mood disorders may in some cases show structural differences from  those without them. Videbech and Ravnkilde (2004) found that the hippocampus was smaller in depressed subjects than in normal subjects, and this may be the result of reduced neurogenesis (the process of generating new neurons) in depressed people (Warner-  Schmidt & Duman, 2006). Antidepressant drugs may alleviate depression in part by  increasing neurogenesis (Duman & Monteggia, 2006). People who experience stressful life events, for instance involving threat, loss, humiliation, or defeat, are likely to experience depression. But biological-situational models suggest that a person‘s sensitivity to stressful events depends on his or her genetic makeup. The researchers therefore expected that people with one type of genetic pattern would show depression following stress to a greater extent than people with a different type of genetic pattern. One group had a short version (orallele) of the gene, whereas the other group did not have the short allele of the gene. The participants also completed a measure where they indicated the number and severity of stressful life events that they had experienced over the past 5 years. The events included employment, financial, housing, health, and relationship stressors. The dependent measure in the study was the level of depression reported by the participant, as  assessed using a structured interview test (Robins, Cottler, Bucholtz, & Compton, 1995). But for the participants who did not have a short allele, increasing stress did not increase depression (bottom panel). Furthermore, for the participants who experienced 4 stressors over the past 5 years, 33% of the participants who carried the short version of the gene became depressed, whereas only 17% of participants who did not have the short version did. This important study provides an excellent example of how genes and environment work together: An individual‘s response to environmental stress was influenced by his or her genetic makeup. But psychological and social determinants are also important in creating mood disorders and depression. In terms of psychological characteristics, mood states are influenced in large part by our cognitions. Negative thoughts about ourselves and our relationships to others create negative moods, and a goal of cognitive therapy for mood disorders is to attempt to change people‘s Attributed to Charles Stangor Saylor. Negative moods also create negative behaviors toward others, such as acting sad, slouching, and avoiding others, which may lead those others to respond negatively to the person, for instance by isolating that person, which then creates even more depression (Figure 12. You can see how it might become difficult for people to break out of this “cycle of depression. These differences seem to be due to discrepancies between individual feelings and cultural expectations about what one should feel. People from European and American cultures report that it is important to experience emotions such as happiness and excitement, whereas the Chinese report that it is more important to be stable and calm. If the depression continues and becomes even more severe, the diagnosis may become that of major depressive disorder. Give a specific example of the negative cognitions, behaviors, and responses of others that might contribute to a cycle of depression like that shown inFigure 12. Given the discussion about the causes of negative moods and depression, what might people do to try to feel better on days that they are experiencing negative moods? Aspinall, Apsychology of human strengths: Fundamental questions and future directions for a positive psychology (pp. Hedonic tone and activation level in the mood-creativity link: Toward a dual pathway to creativity model. Hippocampal neurogenesis: Opposing effects of stress and antidepressant treatment. Identify the biological and social factors that increase the likelihood that a person will develop schizophrenia. The term schizophrenia, which in Greek means “split mind,‖ was first used to describe a psychological disorder by Eugen Bleuler (1857–1939), a Swiss psychiatrist who was studying patients who had very severe thought disorders. Schizophrenia is a serious psychological disorder marked by delusions, hallucinations, loss of contact with reality, inappropriate affect, disorganized speech, social withdrawal, and deterioration of adaptive behavior. Schizophrenia is the most chronic and debilitating of all psychological disorders. It affects men and women equally, occurs in similar rates across ethnicities and across cultures, and affects at any one time approximately 3 million people in the United States (National Institute of Mental  Health, 2010). Onset of schizophrenia is usually between the ages of 16 and 30 and rarely Attributed to Charles Stangor Saylor. Symptoms of Schizophrenia Schizophrenia is accompanied by a variety of symptoms, but not all patients have all of them (Lindenmayer & Khan, 2006). Finally, cognitive symptoms are the changes in cognitive processes that accompany schizophrenia (Skrabalo, 2000). Auditory hallucinations are the most common and are reported by approximately three quarters  of patients (Nicolson, Mayberg, Pennell, & Nemeroff, 2006). Schizophrenic patients frequently report hearing imaginary voices that curse them, comment on their behavior, order them to do  things, or warn them of danger (National Institute of Mental Health, 2009). Visual hallucinations are less common and frequently involve seeing God or the devil (De Sousa,  2007). Schizophrenic people also commonly experience delusions, which are false beliefs not commonly shared by others within one’s culture, and maintained even though they are obviously out of touch with reality. People with delusions of grandeur believe that they are important, famous, or powerful. They often become convinced that they are someone else, such as the president or God, or that they have some special talent or ability. Some claim to have been assigned to a  special covert mission (Buchanan & Carpenter, 2005). People with delusions of persecution believe that a person or group seeks to harm them. They may think that people are  able to read their minds and control their thoughts (Maher, 2001). If a person suffers from delusions of persecution, there is a good chance that he or she will become violent, and this  violence is typically directed at family members (Buchanan & Carpenter, 2005). People suffering from schizophrenia also often suffer from the positive symptom of derailment—the shifting from one subject to another, without following any one line of thought to conclusion—and may exhibit grossly disorganized behavior including inappropriate sexual behavior, peculiar appearance and dress, unusual agitation (e. Movement disorders typically appear as agitated movements, such as repeating a certain motion again and again, but can in some cases include catatonia, a state in which a person does not move and is unresponsive to others (Janno, Holi, Tuisku, & Wahlbeck,  2004; Rosebush & Mazurek, 2010). Patients often suffer from flat affect, which means that they express almost no emotional response (e. Another negative symptom is the tendency toward incoherent language, for instance, to repeat the speech of others (“echo speech‖). Some schizophrenics experience motor disturbances, ranging from complete catatonia and apparent obliviousness to their environment to random and frenzied motor activity during which they become hyperactive  and incoherent (Kirkpatrick & Tek, 2005). Not all schizophrenic patients exhibit negative symptoms, but those who do also tend to have the  poorest outcomes (Fenton & McGlashan, 1994). Negative symptoms are predictors of deteriorated functioning in everyday life and often make it impossible for sufferers to work or to care for themselves. Cognitive symptoms of schizophrenia are typically difficult for outsiders to recognize but make it extremely difficult for the sufferer to lead a normal life. These symptoms include difficulty comprehending information and using it to make decisions (the lack of executive control), difficulty maintaining focus and attention, and problems with working memory (the ability to use information immediately after it is learned). Rather, a variety of biological and environmental risk factors interact in a complex way to increase the likelihood that someone might develop  schizophrenia (Walker, Kestler, Bollini, & Hochman, 2004). Studies in molecular genetics have not yet identified the particular genes responsible for schizophrenia, but it is evident from research using family, twin, and adoption studies that  genetics are important (Walker & Tessner, 2008). Neuroimaging studies have found some differences in brain structure between schizophrenic and normal patients. In some people with schizophrenia, the cerebral ventricles (fluid-filled spaces in  the brain) are enlarged (Suddath, Christison, Torrey, Casanova, & Weinberger, 1990). People with schizophrenia also frequently show an overall loss of neurons in the cerebral cortex, and some show less activity in the frontal and temporal lobes, which are the areas of the brain involved in language, attention, and memory. This would explain the deterioration of functioning Attributed to Charles Stangor Saylor. Many researchers believe that schizophrenia is caused in part by excess dopamine, and this theory is supported by the fact that most of the drugs useful in treating schizophrenia inhibit  dopamine activity in the brain (Javitt & Laruelle, 2006).
Journal of Psychiatric and tative generic avanafil 50 mg on-line, in-depth look at a phenomenon buy discount avanafil 200 mg online, a Mental Health Nursing cheap avanafil 200mg line, 2 generic avanafil 50mg with visa, 77–84. Recovering from depression: A one-year an intervention directed at the phenomenon. The evolution of an intervention: The use of highly revolutionary at the time; few of her Peplau’s process of practice-based theory development. Negative thinking mediates the effect of self-esteem on de- based theory development as a research pressive symptoms in college women. The identiﬁcation of a clinical Preventing depression in high-risk college women:A report of problem and an in-depth look at its etiology, an 18-month follow-up. As interven- Negative thinking and the mental health of low-income single tions were tested and supported in clinical re- mothers. Applied Peplau’s theory to examine the psychosocial factors associated Psychological Measurement, 1, 385–401. Hildegard Peplau meets family systems nursing: Innovation in theory-based practice. Journal of Psychiatric and Mental Health parts: Martha Rogers and Hildegard Peplau. Treating depression through the nurse- ing movement of chronic psychiatric patients from the orien- client relationship. Nursing Clinics of North America, 33, tation to the working phase of the nurse-client relationship 153–172. Professional Nurse, 10(4), versal for women in a primary care setting: A pilot study. Personal, impersonal, and interpersonal rela- Psychiatric Nurses Association, 6, 119–125. Peplau’s Process of Practice-based Theory Development and Its Applications 67 practice... A therapeutic behavior Thoughts on completion of translation of basic principles of scale. Journal of the American Psychiatric Nurses Association, for developing self-awareness. Research in Nursing and Health, 2(1), Perspectives in Psychiatric Care, 18(2), 67–89. A personal responsibility: A discussion of framework for application in nursing practice. Professional closeness as a special kind of involvement with a patient, client or family group. Peplau’s Process of Practice-based Theory Development and Its Applications 69 Peplau,H. Ernestine Wiedenbach, Virginia Henderson, and Ernestine Wiedenbach died in April 1998 at the age Ida Jean Orlando are three of the most important of 98 (Gesse & Dombro, 1992, p. The work of each of these nurse scholars was based on Ida Jean Orlando was born in 1926 in New York. Concepts College School of Nursing where she received a and terms they ﬁrst used are heard today around diploma in nursing. John’s University in Brooklyn, New York, and these three important twentieth-century nursing in 1954 she completed a master’s degree in nurs- theorists. Orlando’s early work from scholars who have studied or worked nursing practice experience included obstetrics, with these theorists and who wrote chapters about medicine, and emergency room nursing. Her ﬁrst each for Nursing Theories and Nursing Practice 1st book, The Dynamic Nurse-Patient Relationship: edition. To the extent possible, content written by Function, Process and Principles (1961), was based each of the identiﬁed authors is used. For a wealth on her research and blended nursing practice, of additional information on these nurses, scholars, psychiatric–mental health nursing, and nursing ed- researchers, thinkers, writers, practitioners, and ed- ucation. It was published when she was director ucators, please consult the reference and bibliogra- of the graduate program in mental health and phy sections at the end of this chapter. She received a bachelor of arts degree from tative and inductive, using naturalistic inquiry Wellesley College in 1922. As a consultant at McLean Hospital in Johns Hopkins School of Nursing in 1925 (Nickel, Belmont, Massachusetts, Orlando continued to Gesse, & MacLaren, 1992. After completing a study nursing practice and developed a training master of arts at Columbia Univeristy in 1934, she program and nursing service department based on became a professional writer for the American her theory. With two opment of prescriptive theory (Dickoff, James & of her brothers serving in the armed forces during Wiedenbach, 1968). Even after her retirement in World War I and in anticipation of a critical short- 1966, she and her lifelong friend Caroline Falls of- age of nurses, Virginia Henderson entered the Army fered informal seminars in Miami, always remind- School of Nursing at Walter Reed Army Hospital. It ing students and faculty of the need for clarity of was there that she began to question the regimen- purpose, based on reality. She even continued to talization of patient care and the concept of nurs- use her gift for writing to transcribe books for the ing as ancillary to medicine (Henderson, 1991). Her pioneer work in the area of “series of almost unrelated procedures, beginning identifying and structuring nursing knowledge has with an unoccupied bed and progressing to aspira- provided the foundation for nursing scholarship tion of body cavities” (Henderson, 1991, p. Henderson admired Goodrich’s intel- Introducing the Theories lectual abilities and stated: “Whenever she visited our unit, she lifted our sights above techniques Virginia Henderson, sometimes known as the and routine” (Henderson, 1991, p. Henderson modern day Florence Nightingale, developed the credited Goodrich with inspiring her with the deﬁnition of nursing that is most well known inter- “ethical signiﬁcance of nursing” (Henderson, 1991, nationally. Ida Jean Orlando was perhaps the ence forever inﬂuenced her ethical understanding ﬁrst nurse to use qualitative research methods and of nursing and her appreciation of the importance was the ﬁrst to articulate nursing concepts based on and complexity of the nurse-patient relationship. Each of these She continued to explore the nature of nursing nurses helped us focus on the patient, instead of on as her student experiences exposed her to different the tasks to be done, and to plan care to meet needs ways of being in relationship with patients and of the person. For instance, a pediatric experience caring based on the perspective of the individual as a student at Boston Floating Hospital introduced being cared for—through observing, communicat- Henderson to patient-centered care in which ing, designing, and reporting. Each was concerned nurses were assigned to patients instead of tasks, with the unique aspects of nursing practice and and warm nurse-patient relationships were encour- scholoarship and with the essential question of, aged (Henderson, 1991). She enjoyed the less formal vis- Initial work on Wiedenbach’s prescriptive theory is iting nurse approach to patient care and became presented in her article in the American Journal skeptical of the ability of hospital regimes to alter of Nursing (1963) and her book, Meeting the patients’ unhealthy ways of living upon returning Realities in Clinical Teaching (1969). She entered Teachers tion of prescriptive theory is that:“Account must be College at Columbia University, earning her bac- calaureate degree in 1932 and her master’s degree “Account must be taken of the motivating in 1934. She continued at Teachers College as an in- factors that inﬂuence the nurse not only in structor and associate professor of nursing for the doing what she does but also in doing it next 20 years. Henderson wrote about nursing the way she lived it: focusing on what taken of the motivating factors that inﬂuence the nurses do, how nurses function, and on nursing’s nurse not only in doing what she does but also in unique role in health care. Her works are beauti- doing it the way she does it with the realities that fully written in jargon-free, everyday language. The nurse’s central purpose in nursing is the • The Recipient, or the patient receiving this nurse’s professional commitment. For Wiedenbach, action or on whose behalf the action is the central purpose in nursing is to motivate the taken; individual and/or facilitate his efforts to over- • The Framework, comprised of situational fac- come the obstacles that may interfere with his tors that affect the nurse’s ability to achieve ability to respond capably to the demands made nursing results; of him by the realities in his situation • The Goal, or the end to be attained through (Wiedenbach, 1970, p. She emphasized that nursing activity on behalf of the patient; the nurse’s goals are grounded in the nurse’s • The Means, the actions and devices through philosophy, that “those beliefs and values that which the nurse is enabled to reach the shape her attitude toward life, toward fellow goal. She rec- in whatever setting they are found for the purpose of ognized that nurses have different values and avoiding, relieving, diminishing or curing the indi- various commitments to nursing and that to vidual’s sense of helplessness. Following is an overview of the major nurse to undergo this experience and be “willing components of Orlando’s work. The nursing process includes identifying needs nursing for examination and discussion when of patients, responses of the nurse, and nursing appropriate” (Wiedenbach, 1970, p. The prescription indicates the broad general ac- practiced by Orlando, is not the linear model tion that the nurse deems appropriate to fulﬁll- often taught today, but is more reﬂexive and ment of her central purpose. The nurse will have circular and occurs during encounters with thought through the kind of results to be sought patients. Understanding the meaning of patient behavior accepting accountability for what she does and is influenced by the nurse’s perceptions, for the outcomes of her action. It may be validated then, is deliberate action that is mutually under- through communication between nurse and pa- stood and agreed upon and that is both patient- tient. Patients experience distress when they directed and nurse-directed (Wiedenbach, cannot cope with unmet needs. The realities are the aspects of the immediate nurs- ior to discover distress and meaning. Nurse-patient interactions are unique, complex, achieves through what she does (Wiedenbach, and dynamic processes. Professional nurses function in an independent • The Agent, who is the nurse supplying the role from physicians and other health-care nursing action; providers.
Just as you can’t power a lamp with a lump of coal buy avanafil 100mg on-line, cells can’t use glucose directly order avanafil 100mg with mastercard. Chapter 2 The Cell: Life’s Basic Building Block In This Chapter Breaking through the cell membrane Aiming for the nucleus Sorting through what’s inside the cell Putting together proteins made to order Following the cell cycle ytology avanafil 50 mg visa, from the Greek word cyto generic avanafil 200 mg with visa, which means “cell,” is the study of cells. Every living Cthing has cells, but not all living things have the same kinds of cells. Eukaryotes like humans (and all other organisms besides bacteria and viruses) have eukaryotic cells, each of which has a defined nucleus that controls and directs the cell’s activities, and cytosol, fluid material found in the gel-like cytoplasm that fills most of the cell. Plant cells have fibrous cell walls; animal cells do not, making do instead with a semipermeable cell mem- brane, which sometimes is called a plasma membrane or the plasmalemma. Because human cells don’t have cell walls, they look like gel-filled sacs with nuclei and tiny parts called organelles nestled inside when viewed through an electron microscope. In this chapter, we help you sort out what makes up a cell, what all those tiny parts do, and how cells act as protein-manufacturing plants to support life’s activities. Gaining Admission: The Cell Membrane Think of it as a gatekeeper, guardian, or border guard. Despite being only 6 to 10 nanometers thick and visible only through an electron microscope, the cell membrane keeps the cell’s cytoplasm in place and lets only select materials enter and depart the cell as needed. This semipermeability, or selective permeability, is a result of a double layer (bilayer) of phospho- lipid molecules interspersed with protein molecules. The outer surface of each layer is made up of tightly packed hydrophilic (or water-loving) polar heads. Inside, between the two layers, you find hydrophobic (or water-fearing) nonpolar tails consisting of fatty acid chains. Cholesterol molecules between the phosphate layers give the otherwise elastic membrane stability and make it less permeable to water-soluble substances. Both cytoplasm and the matrix, the material in which cells lie, are primarily water. The polar heads electrostatically attract polarized water molecules while the nonpolar tails lie between the layers, shielded from water and creating a dry middle layer. The membrane’s interior is made up of oily fatty acid molecules that are electrostatically symmetric, or nonpolarized. Lipid-soluble molecules can pass through this layer, but water-soluble molecules such as amino acids, sugars, and proteins cannot. Because phospholipids have both polar and nonpolar regions, they’re also called amphipathic molecules. Part I: Building Blocks of the Body 24 The cell membrane is designed to hold the cell together and to isolate it as a distinct functional unit of protoplasm. Although it can spontaneously repair minor tears, severe damage to the membrane will cause the cell to disintegrate. It allows movement across its barrier by diffusion, osmosis, or active transport as follows: D i f f u s i o n : This is a spontaneous spreading, or migration, of molecules or other particles from an area of higher concentration to an area of lower concentration until equilibrium occurs. When equilibrium is reached, diffusion continues, but the flow is equal in both directions. Diffusion is a natural phenomenon that behaves in much the same way as Brownian motion; both phenomena are based on the fact that all molecules possess kinetic energy. They move randomly at high speeds, colliding with one another, changing directions, and moving away from areas of greatest concentration to areas of lower concentration. The rate of movement depends on the size and temperature of the molecule; the smaller and warmer the molecule is, the faster it moves. Diffusion is one form of passive transport that doesn’t require the expenditure of cellular energy. A molecule can diffuse passively through the cell membrane if it’s lipid-soluble, uncharged, and very small, or if it can be assisted by a carrier molecule. The unassisted diffusion of very small or lipid-soluble particles is called simple diffusion. The cell membrane allows nonpolar molecules (those that don’t readily bond with water) to flow from an area where they’re highly concentrated to an area where they’re less concentrated. Embedded with the hydrophilic heads in the outer layer are protein molecules called channel proteins that create diffusion-friendly openings for the molecules to diffuse through. O s m o s i s : This form of passive transport is similar to diffusion and involves a sol- vent moving through a selectively permeable or semipermeable membrane from an area of higher concentration to an area of lower concentration. The solvent is the liquid in which a substance is dissolved; water is called the universal solvent because more materials dissolve in it than in any other liquid. Typically, a cell contains a roughly 1 percent saline solu- tion — in other words, 1 percent salt (solute) and 99 percent water (solvent). Water is a polar molecule that will not pass through the lipid bilayer; however, it is small enough to move through the pores of most cell membranes. Osmosis occurs when there’s a difference in molecular concentration of water on the two sides of the membrane. The membrane allows the solvent (water) to move through but keeps out the particles dissolved in the water. Transport by osmosis is affected by the concentration of solute (the number of particles) in the water. Osmolarity is the term used to describe the concentration of solute par- ticles per liter. Eventually, the pressure within the cell becomes equal to, and is bal- anced by, the osmotic pressure outside. An example is 100 percent distilled water, which has less solute than what’s inside the cell. Therefore, if a human cell is placed in a hypo- tonic solution, molecules diffuse down the concentration gradient until the cell’s membrane bursts. Chapter 2: The Cell: Life’s Basic Building Block 25 •Ahypertonic solution has more solute and lower water potential than inside the cell. So the membrane of a human cell placed in 10 percent saline solu- tion (10 percent salt and 90 percent water) would let water flow out of the cell (from higher concentration inside to lower concentration outside), therefore shrinking it. Embedded with the hydrophilic heads in the outer layer of the membrane are protein mole- cules able to detect and move compounds through the membrane. The carrier molecules combine with the transport molecules — most importantly amino acids and ions — to pump them against their concentration gradients. Active transport lets cells obtain nutrients that can’t pass through the mem- brane by other means. In addition, there are secondary active transport processes that are similar to diffusion but instead use imbalances in electrostatic forces to move molecules across the membrane. Fill in the blanks to complete the following sentences: The lipid bilayer structure of the cell membrane is made possible because phospholipid molecules contain two distinct regions: The 1. Because it has both polar and non- polar regions, a phospholipid is classified as a(n) 3. A solution having a greater concentration of water than exists in the cell is said to be a. Injecting a large quantity of distilled water into a human’s veins would cause many red blood cells to a. As containment for the cytoplasm Part I: Building Blocks of the Body 26 Aiming for the Nucleus The cell nucleus is the largest cellular organelle and the first to be discovered by scien- tists. On average, it accounts for about 10 percent of the total volume of the cell, and it holds a complete set of genes. The outermost part of this organelle is the nuclear envelope, which is composed of a double-membrane barrier, each membrane of which is made up of a phospholipid bilayer. Between the two membranes is a fluid-filled space called the perinuclear cis- terna. The two layers fuse to form a selectively permeable barrier, but large pores allow relatively free movement of molecules and ions, including large protein mole- cules. Intermediate filaments lining the surface of the nuclear envelope make up the nuclear lamina, which functions in the disassembly and reassembly of the nuclear membrane during mitosis and binds the membrane to the endoplasmic reticulum. The nucleus also contains nucleoplasm, a clear viscous material that forms the matrix in which the organelles of the nucleus are embedded.
Chest radi- ography reveals fractures of the seventh and eighth ribs of the right anterolat- eral chest buy avanafil 200mg low price. Which of the following is the most appropriate treatment for this patient’s rib fractures? On the secondary survey discount avanafil 100mg with visa, you note motor weakness of his left lower extremity and the loss of pain sensation in the right lower extremity discount 200 mg avanafil with mastercard. A bystander tells paramedics that the patient was punched and kicked multiple times and sustained multiple blows to his head with a stool discount 100 mg avanafil free shipping. He states he was wearing his seat belt in the driver’s seat when a car hit him from behind. He thinks his chest hit the steering wheel and now complains of pain with breathing. The stab wound is located between the angle of the mandible and the cricoid cartilage and violates the platysma. Radiographs of the cer- vical spine reveal bilateral fractures of the C2 vertebra. A 71-year-old man is found lying on the ground one story below the balcony of his apartment. On examination, you note clear fluid dripping from his left ear canal and an area of ecchymosis around the mastoid bone. He has obvi- ous head trauma with a scalp laceration overlying a skull fracture on his occiput. He does not speak when asked his name, his respirations are poor and you hear gurgling with each attempted breath. His pelvis is unstable with movement laterally to medially and you note blood at the urethral meatus. His right leg is grossly deformed at the knee and there is an obvious fracture of his left arm. Create two Burr holes into the cranial vault to treat a potential epidural hematoma. Immediately reduce the extremity injuries and place in a splint until the patient is stabilized. Plan for endotracheal intubation of the airway with in-line stabilization of the cervical spine. A 20-year-old man was found on the ground next to his car after it hit a tree on the side of the road. Bystanders state that the man got out of his car after the collision but collapsed within a few minutes. She cannot wiggle her toes, has 1/5 motor function of her quadriceps, and only patchy lower extremity sensation. Which of the fol- lowing statements is most appropriate regarding management of a hypotensive trauma patient who fails to respond to initial volume resuscitation? Secondary survey reveals an unstable pelvis upon movement with lateral to medial force. Which of the following is the most appropri- ate immediate next step in management? The lifeguard on duty accompanies the patient and states that he dove head first into the shallow end of the pool and did not resurface. On examination, the patient is speaking but cannot move his arms or legs and cannot feel pain below his clavicle. When examining his cervical spine, he denies tenderness to palpation and you do not feel any bony deformities. Cerebral atrophy in the elderly population provides protection against subdural hematomas. Increased elasticity of their lungs, allows elderly patients to recover from tho- racic trauma more quickly than younger patients. The most common cervical spine fracture in this age group is a wedge fracture of the sixth cervical vertebra. Despite lack of cervical spine tenderness, imaging of his cervical spine is warranted. His breath sounds are equal bilaterally and chest wall is without contusion or bony crepitus. Which of the following organs is most likely to be injured in blunt abdominal trauma? When you are testing his extraocular muscles, you note that his right eye cannot look superiorly but his left eye can. On abdominal examination, you note a single bullet entry wound approximately 1 cm to the right of the umbilicus. During the log roll, you see a single bullet exit wound approximately 3 cm to the right of the lumbar spine. After 25 minutes of bilateral pressure on her nasal septum, there is still profuse bleeding. Under direct visualization, you note the bleeding originating from the posterior aspect of her septum. Place posterior nasal packing, start antibiotics, and admit the patient to a mon- itored hospital bed. Keep pressure on her nasal septum and administer fresh frozen plasma and platelets. Place posterior nasal packing, and discharge the patient home with follow-up in 24 hours. You notice that his left foot is severely deformed and there is a large laceration to his right arm. In addition to hypoxemia, what condition must be considered earliest in the management of this patient? She is speaking but com- plains of progressively worsening shortness of breath and hemoptysis. On extremity examination, the right foot is pale and you cannot palpate a distal pulse but can locate the dorsalis pedis by Doppler. As you open her eye lids, you notice that her right pupil is 8 mm and nonreactive and her left is 4 mm and minimally reactive. Supine chest radiograph reveals a hazy appearance over the entire right lung field. You place a 36F chest tube into the right thoracic cavity and note 1200 cc of blood in the chest tube drainage system. The patient was the front-seat passenger of the car and was not wearing a seat belt. The patient was wearing a seat belt in the back seat of a car that was struck in the front by another car. Her airway is patent, breath sounds equal bilaterally, and skin is warm with 2+ pulses. He states that the pain started on the left side of his lower back and now involves the right and radiates down both legs. He has a medical history of chronic hypertension and underwent a “vessel surgery” many years earlier. Upon arrival, she does not open her eyes, is verbal but not making any sense, and withdraws to painful stimuli. As you prepare to intu- bate the patient, a colleague notices that her left pupil has become dilated compared to the right. The man tells you his name and complains of right-sided chest pain and difficulty breathing. On primary survey, his airway is patent and his oropharynx has no blood or displaced teeth. He is breathing at 32 beats per minute with retractions and an oxygen saturation of 88% on 15 L of oxygen. These individuals are often amnestic to the event and frequently ask the same questions over and over again (perseverations). Headache with or without vomiting is generally present; however, there are no focal neurologic findings on examination.