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Edition ENA Test Bank |Graded A+ pass
With venous bleeds, direct pressure isusually sufficient to stop the flow. Widening pulse pressure Why is CONTINUOUS ICP MONITORING important? - ansImportant for assessing brain injury and response of patient to treatment. It can provide early detection of secondary brain injury such as cerebral hypoxia, ischemia. Why do partial amputations have more severe bleeding than complete amputations? - ansThe severed arteries retract with complete amputations While in ED, alignment and protection of the cervical spine can be accomplished by which 2 ways? - ans- Manual stabilization When the medial portion of the temporal lobe (uncus) is pushed toward the tentorium and puts pressure on the brain stem, herniation compresses CN III, the motor tract, and the reticular activating system on the same side, resulting in a dilated or blown pupil on the same side, motor weakness on the opposite side, and respiratory dysfunction, progressing to coma. When someone suffers a GSW, below what part of the body is considered an abdominal injury that requires an exploratory laparotomy? - ansBelow the nipple line When patient is receiving massive blood transfusions it is important to closely monitor which electrolytes? Why? - ansHigh K, Low C When immobilizing a patient, you should secure the torso first, then the head, the legs, and the pelvis. When does the secondary survey (HI) begin? - ansAfter the completion of the primary survey (ABCDE), after the initiation of resuscitation efforts, once vital functions have been stabilized and after consideration for resuscitation adjuncts (FG). When does the approach to trauma care typically begin? - ansWith notification that a trauma patient is arriving to ED When does operative management occur? - ansNon- serial abdominal exams What symptoms usually indicate an INTRAOCULAR foreign body is present? - ans- IRREGULAR PUPIL What should you avoid using with fingers, toes or other areas where vasoconstriction could cause impaired distal blood circulation? - ansLIDOCAINE with EPI What lab studies are used to guide resuscitative efforts in shock? - ans- Platelet count, clotting studies What is used to diagnosis renal injuries? What are the cons? How are rectal injuries often managed? - ansSigmoidoscopy What is the standard of care in the hemodynamically STABLE patient who sustained blunt liver injury? - ansNon-operative management What is the most major cause of preventable death after injury? - ansUncontrolled hemorrhage What is the most common cause of thoracic trauma? - ansMVC's What is the difference between penetrating and perforating in regards to ocular injuries?
- ansPenetrating - having ENTRANCE WOUND, an INTRAOCULAR FOREIGN BODY when they are present What is one unique post-operative risk following a splenectomy? Explain. - ansPNEUMOCOCCAL SEPSIS
Edition ENA Test Bank |Graded A+ pass
What does 'safe practice' mean? - ansMeans taking into consideration the protection of the team, including: What does 'safe care' mean? - ansMeans assuring the patient is getting to the right hospital in the right amount of time for the right care. What does non-operative management include? What do you do with open wounds? - ansCover in saline-soaked dressings What diagnostic exam is helpful to inspect abdominal spaces for spillage and to examine loops of bowel? - ansLaparoscopy What can you do to easily see eyes that have abrasions? - ansStain them with fluorescein What can you assess to ensure the brainstem is intact? - ansEXTRAOCULAR EYE MOVEMENTS (EOMs) - tests functions of CNs III, IV, and VI What are two examples of obstructive shock that may result from trauma? - ansTENSION PNEUMOTHORAX and CARDIAC TAMPONADE What are the two priorities in treating patients with TBI? - ansFacilitating OXYGENATION and VENTILATION What are the rules concerning standard imaging in relation to eye injury - ans- If wood or a vegetative foreign body is suspected, MRI most appropriate imaging method to use, however, it is minimally useful in acute setting What are the late signs that may indicate a tension pneumothorax? - ansJVD and tracheal deviation What are some circumstances that may lead to unreliable pulse ox readings? - ans- Poor peripheral perfusion What are some assessment findings for patients who sustain a pancreatic injury? - ans- Serial serum amylase levels increasing over time may indicate but this does not constitute a definitive diagnosis What are signs of worsening hypoxia with nerve injuries? - ansIncreased pain even when pulses remain present, often the first sign of increased compartment pressures What are odors you want to be sure to document? - ansAlcohol, gasoline, other chemicals What are late signs of MEDIASTINAL SHIFT? - ansNECK VEIN DISTENTION from increased intrathroatic pressure and TRACHEAL DEVIATION What are complications related to crush injuries? - ansCompartment syndrome, hyperkalemia, rhabdomyolysis What are causes of peritoneal membrane irritation? - ans- presence of blood Was there a cardiac event prior to injury? VISCERAL PAIN originates from organs and may lead to referred pain Venous bleeding typically results in a steady flow of dark red blood. V- responds to VERBAL stimuli, airway adjunct may be needed to keep tongue from obstructing airway Use the jaw-thrust maneuver to open airway and assess for obstruction when the patient is... - ansUnable to open the mouth, responds only to pain, or is unresponsive. Use the DOPE mnemonic to troubleshoot ventilator or capnography alarms - ansD - Displaced tube
Edition ENA Test Bank |Graded A+ pass
The science of medicine provides the principles of medical care. Simply stated, principles define the duties required of the prehospital care practitioner in optimizing patient survival and outcome. The proper level to maintain is between 35 and 40 mm Hg. The physical environment (socioeconomic environment) The patient's age, use of a blood thinner, and the fact she fell recently point to a subdural hematoma. The patient does not need more fluids right now. Giving morphine in a shocked patient is a risky move and could lead to dangerous hypotension. The most reliable indicator of an intraabdominal bleed is the presence of hypovolemic shock from an unexplained source. The major assessment parameters that produce important information within seconds of a patient's arrival are... - ans1. Level of consciousness The increase of the diastolic blood pressure with a narrowing pulse pressure... - ansMay be one of the first CONCRETE measurements signaling that the patient's circulatory status is compromised. The host (human) The Haddon Matrix broadened the approach and placed emphasis on countermeasures, such were more effective than changing human behavior. Haddon describes three phases of the injury event: - ansPre-event, Event, Post-event The device reflects oxygen delivery to cerebral tissues and monitors temperature The degree to which tissues resist destruction under circumstances of energy transfer depends on... - ansTheir proximity to the impact and their structural characteristics The assessment of circulation during the primary survey includes... - ansEarly evaluation of the possibility of hemorrhage in the abdomen and pelvis in any patient who has sustained blunt trauma. The A-I mnemonic helps the trauma nurse rapidly assess for and intervene in life- threatening injuries and identify all injuries in a systematic manner. - ansA: airway and alertness with simultaneous cervical spinal stabilization The agent (motor vehicle) The "X" placed before "ABCDE" in the primary survey refers to the need to address exsanguinating hemorrhage immediately after establishing scene safety and before addressing airway. Severe exsanguinating hemorrhage, particularly arterial bleeding, has the potential to lead to loss of total or near total blood volume in a relatively short period of time. Tertiary: Improvement of outcomes related to the traumatic injury TENSION PNEUMOTHORAX - ansOccurs when air enters INTRAPLEURAL space but cannot escape on expiration, increasing pressure causes lung on injuries side to collapse. If pressure not relieved, mediastinum can shift toward the uninjured side compressing heart, great vessels, and ultimately the opposite lung. Tensile strength describes the tissue's ability to: - ansResist pulling apart when stretched
Edition ENA Test Bank |Graded A+ pass
Tears or lacerations of the tracheobronchial tree disrupt the... - ansIntegrity of the upper and lower airways... Patients initially present with dramatic symptoms, such as... Sudden vision changes may indicate________ in the cerebral vascular - ansA POSSIBLE FAT EMBOLISM Structural strengths of tissue are described in what three ways? - ans-Compression Stage III: Irreversible Shock - ans- Obtunded, stuporous, comatose Stage II: Decompenstated or Progressive Shock - ans- LOC deteriorates patient becomes obtunded or unconscious as cell switch to anaerobic metabolism with increasing levels of lactic and pyruvic acids Stage I: Compensated Shock - ans- Anxiety, lethargy, confusion, restlessness from oxygen being shunted to brainstem SPINAL SHOCK - ansWhen spinal cord is injured, cascade of events takes place Spinal cord neurons DO NOT regenerate; therefore, severe injury with cellular death may result in... - ans- temporary or permanent loss of function Signs of increased work of breathing, tachypnea, SOB, tachycardia, hypotension, and unilateral decrease in breath sounds on injuries side... - ansSignifies decreased cardiac output. Caused when air or blood accumulates in thoracic cavity causing increase in INTRAPLEURAL pressure on side of injury. If this pressure is allowed to expand without intervention, it can produce a MEDIASTINAL SHIFT which compresses heart and great vessels, resulting in a DECREASE in VENOUS RETURN (PRELOAD) and SUBSUQUENT DECREASE IN CARDIAC OUTPUT. Signs of hypocalemia include- dysrhythmias, muscle tremors, and seizures Shift to the LEFT occurs in an environment of LOW metabolic demand. Hemoglobin's affinity for oxygen increases, making it harder to release bound oxygen to the tissues. A shift to the right occurs in response to: Shear strength describes the tissue's ability to: - ansResist a force applied parallel to the tissue
- Shear Severe DAI lasts weeks to months SEVERE Secondary: Reduction in the severity of the injury that has occurred Scald burns are the most common burns seen in the pediatric population ages 1 to 5 years. Scalds are partial thickness burns. The dermal layer is damaged, and blisters are present or popped. It is also the most painful type of burn. SAMPLE mnemonic regarding patient's history - ansS - Symptoms associated with injury S: This is a Safety issue/ I am Stressed S: Suggest alternatives and seek agreement RUPTURED DIAPHRAGM - ansAssessment findings RSI pretreatment medications ROTATIONAL - ansetiology/cause- combination of forceful forward flexion with lateral displacement of cervical spine rigidity, spasm, or involuntary guarding
Edition ENA Test Bank |Graded A+ pass
Physiologic effects of pain by system: Immune - ansDECREASED RESPONSE Physiologic effects of pain by system: Genitourinary - ansDECREASED URINARY OUTPUT Physiologic effects of pain by system: Gastrointestinal - ansDECREASED MOTILITY Physiologic effects of pain by system: Endocrine - ansINCREASED RELEASE OF HORMONES AND MEDIATORS Physiologic effects of pain by system: Cardiovascular - ansHYPERCOAGULATION Pertaining to abdominal trauma, peripheral perfusion perfusion Perforating - having ENTRANCE and EXIT WOUND Penetrating injury to the chest wall and lacerated lung tissue can cause the loss of ________________. Thus, the collection of air or blood in the pleural space causes ______________. - ansA. NORMAL NEGATIVE INTRAPLEURAL PRESSURE PENETRATING injury - firearms or exploding objects or projectiles Pathophysiologic concepts that affect the patient with brain, cranial, or maxillofacial injuries include issues related to... - ans- HYPOTENSION and CBF Palate for: Pain Theories include... - ansGATE CONTROL THEORY- proposes pain may be modulated by interneurons within spinal cord. Stimulation of the large A-beta cutaneous fibers was thought to close gate pain impulses from A-delta or C fibers. A-beta fibers carry impulses from touch, vibration, rubbing a painful area. Supports non- pharmacologic therapies for pain control such as ice, heat, massage. p. 9 p. 9 p. 7 p. 7 p. 7 p. 31 p. 30 p. 28 p. 27 p. 27 p. 27 p. 27 p. 27 p. 27 p. 26 p. 26 p. 26 p. 26 p. 26 p. 25 p. 25
Edition ENA Test Bank |Graded A+ pass
p. 25 p. 11 p. 11 p. 10 P - responds to PAIN. P - Pneumothorax P - Past medical history (hospitalizations/surgeries) P - pain assessment and management Oxyhemoglobin-dissociation curve indicates the correlation of tissue oxygneation (PaO2) as it saturates the hemoglobin molecule (SO2). P50 describes the oxygen pressure when the hemoglobin molecule is 50% saturated. Normal P50 is 26.7 mm Hg. A shift in the curve notes changes in the relationship: - ansShift to the RIGHT occurs in an environment of HIGH metabolic demand. Hemoglobin's affinity for oxygen decreases, making it easier to release the bound oxygen to the tissues. A shift to the right occurs in response to: oximetry and end-tidal carbon dioxide (ETCO2) Output less than 0.5 mL/kg per hour for two consecutive hours indicates... - ansOLIGURIA Others include: Falls, crush injury, assaults, gunshot and stabbing wounds, ped vs. vehicle collisions other assessment findings include: Op- occurs in patients who exhibit signs of peritonitis or hemodynamic instability One of your most importantresponsibilities as a prehospital carepractitioner is to spend as little time onthe scene as possible and expedite yourfield care and transport of the patient.Studies show that the time from injuryto arrival at the appropriate site fordefinitive care is critical to survival. One of the earliest responses to inadequately pefused tissue is... - ansTACHYPNEA Once patient has airway in place, assess for proper placement by... - ans- Presence of adequate rise and fall of the chest with assisted ventilation
- Once Dx is confirmed, it is important to protect eye from further injury Often managed with colostomy and distal rectal washout O - Oxygenation and ventilation assessment O - oxygenation and ventilation analysis: pulse O - Obstructed or kinked tube Now is the time to titrate IV fluids to restore tissue perfusion. Giving 1 liter blindly could overshoot your target pressure and reinforce internal bleeding. TXA is not a priority, although it can run parallel to fluids. Non-invasive near-infrared spectroscopy is used to... - ansmeasure decreased tissue blood flow, useful to diagnose compartment syndrome Newton's Third Law of Motion - ansFor every action, there is an equal and opposite reaction Newton's Second Law of Motion - ansForce = Mass X Acceleration Newton's First Law of Motion - ansA body at rest will remain at rest, and a body in motion will stay in motion
Edition ENA Test Bank |Graded A+ pass
Interventions Interventions Interventions Interventions Interventions Interventions INSULIN RESISTANCE Initial assessment - approach to trauma patient care that requires a process to identify and treat or stabilize life-threatening injuries in an efficient and timely manner. It is divided into the following process points: - ans- Preparation and triage INCREASED RISK OF ATELECTASIS & PNEUMONIA INCREASED OXYGEN DEMAND Increased or bounding central pulses may indicate increased cardiac output. Peripheral pulses do not demonstrate a similar effect in the presence of hypovolemia due to vasocontriction. Thus, strong central pulses combined with weak peripheral pulses may be... - ansIndicative of Shock INCREASED LIPOLYSIS INCREASED CARDIAC WORKLOAD In those cases, an emergent abdominal or pelvic assessment may be preformed to include a focused assessment with sonography for trauma (FAST) examination or a radiograph of the pelvis. In the prehospital setting, blisters are generally best left alone during the relatively short transport time. Blisters that have already ruptured should be covered with a clean, dry dressing. In presence of facial fractures, the inability to perform EOMs may indicate a trapped nerve In a compensated state, CSF and blood volume decrease, while heart rate and blood pressure are still within normal range. IMMOBILITY Imaging studies for bladder and urethral injuries include - ans- CT cystogram used to dx intraperitoneal or extraperitoneal bladder rupture If there are inconsistent data from electronic monitoring devices, reassess to be sure the monitor matches the patient's current clinical condition. However, it is most important to treat the patient, not the monitor, so use other signs and symptoms of potential patient deterioration. If patient's airway is NOT patent: - ans1. Suction airway If injury causes the CPP to fall outside the range between ___________ mm Hg, the brain loses its ability to autoregulate and CBF becomes directly dependent on MAP for perfusion. - ans50 and 160 mm Hg If CPR is being performed, when was it started? If causes by contact lenses, treat for Pseudomonas If breathing is present: - ans1. Administer O2 at 15L/min via nonrebreather mask If breathing is absent: - ans- Open airway using jaw-thrust maneuver while maintaining manual cervical spinal stabilization
Edition ENA Test Bank |Graded A+ pass
If autoregulation fails and MAP is elevated, _______ can result. - ansEDEMA If a penetrating wound is found below the 4th intercostal space, penetration into the _________ is suspected until proven otherwise. - ansABDOMINAL CAVITY I: inspect posterior surfaces HYPOVENTILATION Hypothermia combined with ______ and ______ is a potentially lethal combination. - ansHYPOTENSION and ACIDOSIS HYPOTHERMIA HYPERFLYCEMIA hyperFLEXION - ansetiology/cause- forceful forward flexion with head striking an immovable object hyperEXTENSION - ansetiology/cause- backward thrust beyond anatomic capacity of vertebral column HYPERCARBIA How should you wrap an amputated part? - ansWrap it in slightly saline-moistened sterile gauze, placed in sealed plastic bag THEN place in a second bag containing ice water How high should you elevate limb in compartment syndrome? - ansAt level of heart, any higher can reduce circulation and tissue perfusion. Also ice is strongly contraindicated How can you check for laxity or instability for possible pelvic fractures? - ansgentle pressure over iliac wings DOWNWARD and MEDIALLY How can the trauma nurse have an impact when it comes to the legislative process? - ansBy advocating for stronger laws and more consistent enforcement HEMOTHORAX - anscaused by blood accumulating in the intrapleural space. Results from injury to lung, costal blood vessels, great vessels and from laceration to liver or spleen combined with diaphragm injury. Hemorrhage into space behind globe; bleeding causes increased pressure behind globe causing elevation in IOP that compresses optic nerve and blood vessels. Early recognition is imperative to save vision. H: history and head-to-toe assessment H: HEAD INJURY/HYPOTHERMIA - prevent or treat hypotension and hypoxia to prevent worsening of traumatic brain injury and prevent or treat hypothermia GLUCOSE INTOLERANCE G: get resuscitation adjuncts: For skin, the immediate goal in treating surface trauma is to... and this is accomplished by... - ansOBTAIN AND MAINTAIN HEMOSTASIS, APPLY DIRECT PRESSURE TO SITE For each phase of the event, countermeasures for prevention can be applied. They include: Following the primary survey, FAST examination may be used to rapidly assess for bleeding from damage to the... - ansHeart, liver, kidneys, and spleen. FAST also increasingly used to detect pneumothorax, especially tension pneumothorax. FLUID OVERLOAD
Edition ENA Test Bank |Graded A+ pass
Explain pericardial tamponade and its assessment findings - ansWhen there is a rapid accumulation of blood in pericardial sac, resulting in compression of heart making it difficult for heart to fill during diastole, causing decreased cardiac output. Explain pancreatic injuries - ans- Penetrating pancreatic injuries often sustain concurrent duodenal injuries Explain oligoanalgesia - ansthe concept of undertreatment of pain Explain OBITAL FRACTURE - ans- NOT CONSIDERED OPHTHALMOLOGIC EMERGENCY unless there is IMPAIRED VISION or GLOBE RUPTURE Explain NEUROGENIC SHOCK and what are the assessment findings - ansOccurs with SC damage at T6 or higher, resulting in sympathetic regulation disruption of vagal tone leading to loss of vascular resistance and generalized vasodilation Explain HYPHEMA - ansCollection of blood in anterior chamber of eye - classified as spontaneous or traumatic Explain how to assess circulation and control of hemorrhage in relation to thoracic trauma - ansAuscultation for: Explain GLOBE RUPTURE - ans- Considered a genuine EMERGENCY Explain eye irrigation when used for the removal of chemicals, foreign bodies, and debris from eye - ansCONTRAINDICATED in patients who may have RUPTURED GLOBE Explain emergency thoracotomy - ansDone when patient arrives with unstable vital signs or impending arrest... Indications for performing this include: Explain definitive care on pancreatic trauma - ans- Non-op management including complete bowel rest, nutritional support, serial CT scanning with observation Explain 3 phases of injury prevention - ansPrimary: prevention of the occurrence of the injury Examples of referred pain include... - ans- radiating to left shoulder (Kehr sign) example- rear-end whiplash example- MVC to front or near lateral area of vehicle results in conversion of forward motion to a spinning-type motion example- head-on MVC with head hitting windshield, creating starburst effect example- diver striking head on bottom of pool Ensure safety for responders, bystanders, and patient(s). The first consideration when approaching any scene is the safety of all emergency responders. When EMS personnel become victims, they not only can no longer assist others, but also add to the number of patients. Enforcement and legislation: include laws at all jurisdictional levels regarding driving while intoxicated, booster seats, primary seatbelt use, and distracted driving. For sports this includes rules regarding illegal hits, examination after impact, and return-to-play requirements after a head injury Education: these can be community-based initiatives such as public service announcements for improved seatbelt use, education regarding risks of distracted driving, programs to commit to no texting while driving, and promotions for bicycle helmet giveaways with instructions for proper use
Edition ENA Test Bank |Graded A+ pass
Early treatment for septic shock includes... - ansEarly administration of antibiotics and potential need for norepinephrine to vasoconstrict the peripheral vasculature, increase blood volume return to heart, and improve cardiac output. Early mechanical ventilation via bag mask device or advanced airway measures should be considered in geriatric trauma patients because of their greatly limited physiologic reserve. Early assessment findings of increased ICP include: - ans- HEADACHE E: Express your concerns or how the situation makes you feel E: exposure and environmental control E - Events and Environmental factors related to injury E - Equipment failure, such as patient becoming detached from equipment or loss of capnography waveform During the secondary survey in patient with thoracic or neck trauma, what questions do you want to ask? - ansIf patient is complaining of: During primary survey... - ansLife-threatening conditions are identified and immediately corrected, beginning immediately upon the patient's arrival to the trauma room. Disadvantages of auto-transfusion include: - ans- Risk of contamination Describe the three E's of injury control - ansEngineering: technological interventions such as side impact airbags, automated blind spot alarms, ignition lock devices for those with DUIs. In playgrounds and sports, this involves surface material under playground equipment and athletic safety gear. Another intervention is improved use of smoke alarms in fire prevention Describe the MOI associated with brain, cranial, and maxillofacial trauma - ansBLUNT injury - falls, MVCs, sports-related injuries, recreation Describe SEPTIC SHOCK - ansCaused by systemic release of bacterial endotoxins, resulting in an increased vascular permeability and vasodilation. Describe NEUROGENIC SHOCK - ansOccurs with SCI results in the loss of SNS control of vascular tone, which produces venous and arterial vasodilation. Describe FOCAL BRAIN INJURIES - ansOccur in localized area with grossly observable and identifiable brain lesions. They include... Describe energy forms - ans- Mechanical (energy transfer from one object to another in the form of motion) Describe DISTRIBUTIVE SHOCK - ansOccurs as result of maldistribution of an adequate circulating blood volume with loss of vascular tone or increased permeability. Describe ANAPHYLACTIC SHOCK - ansResults from release of inflammatory mediators (e.g. histamine) which contracts bronchial smooth muscles and increases vascular permeability and vasodilation. Depending on the motorcycle design and rider positioning, the lower extremities can collide with the handlebars, resulting in... - ansFemur and pelvis fractures and hip dislocations Define trauma - ans- Trauma is injury to living tissue caused by extrinsic agent Define mechanism of injury (MOI) - ansHow external energy forces in the environment are transferred to the body
Edition ENA Test Bank |Graded A+ pass
D. Carefully administer IV fluids to raise the patient's systolic blood pressure to between 80 and 90 mm Hg. - ansQuestion 3: D D. Assess the scene and ensure it is safe. - ansQuestion 1: D D. administer TXA. - ansQuestion 3: C D. Administer pain medication. - ansQuestion 2: A D. Administer morphine. - ansQuestion 5: B D. A child's epiglottis is smaller and stiffer than an adult's. - ansQuestion 3: B D. 8 - ansQuestion 2: B D. "No, keep the pressure and let's get out of here!" - ansQuestion 2: D Cough reflex can be blocked using IV... - ansLIDOCAINE Consider ABGs. A decreased level of consciousness may be an indicator of... - ansDecreased cerebral perfusion, hypoventilation, or acid-base imbalance. Cons- unprepared bowel may not detect injury Compression strength refers to the tissue's ability to: - ansResist crush force Compression may occur from the effects of chemical substances and can cause.. - ansEdema, restricting or obstructing the airways, oxygenation, and ventilation. This can result from aspiration of liquids or inhalation of powder or noxious gas. Components of SBAR and its purpose - ansS: Situation Components of DESC and its purpose - ansD: Describe the specific situation or behavior Components of CUS and its purpose - ansC: I am Concerned compare quality between left and right and lower and upper COAGULOPATHY results in depletion of clotting factors through hemodilution and impaired ability to produce clotting factors COAGULOPATHY Clothing can be quickly removed by cutting. You cannot treat what you cannot see. Classifications of acute pain are based on the source and origin and include... - ansSOMATIC pain originates from skin and muscloskeletal structures Classic triad of assessment findings include: Children have larger heads and tongues as compared to an adult so there is a greater potential for airway obstruction in a pediatric patient. You must pay special attention to the proper positioning of a pediatric patient to maintain a patent airway. Ch. 9, p. 120 Ch. 9, p. 119 Ch. 9, p. 118 Ch. 9, p. 116 Ch. 9, p. 115- 116 Ch. 9, p. 115 Ch. 9, p. 115 Ch. 9, p. 115 Ch. 9, p. 115 Ch. 9, p. 114 Ch. 9, p. 114
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