Solid Organ Injury: Liver, Spleen, Pancreas, and Kidneys Practice Questions

25 multiple-choice questions on Solid organ injury: liver, spleen, pancreas, and kidneys for paramedic and EMT students, from Chapter 37 (Abdominal and Genitourinary Trauma). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. You are transferring a patient with a known liver laceration between hospitals. He was stable, but his heart rate rises from 92 to 124 and he becomes restless. You should:

   1. A. Treat it as rebleeding; notify team
   2. B. Assume he is anxious and give him a sedative now
   3. C. Wait until his blood pressure falls to act on it
   4. D. Slow the IV and ask him to breathe more slowly
   Show answer

   Answer: A. Treat it as rebleeding; notify team

   Solid organ injuries managed without surgery can rebleed, and rising heart rate and restlessness are early signs of hemorrhage that appear before hypotension. Reassess, treat for shock per protocol (including blood if available), and notify the receiving trauma team so they can prepare. Sedation and waiting for hypotension delay care.

2. A patient with a suspected splenic injury has a BP of 78/50 mm Hg. After a 250 mL fluid bolus, his BP rises to 98/60 mm Hg, but 10 minutes later it falls again. This pattern suggests:

   1. A. Bleeding that has stopped on its own
   2. B. Ongoing bleeding that needs surgery
   3. C. That he needs only more fluid at home
   4. D. A normal response to a fluid bolus
   Show answer

   Answer: B. Ongoing bleeding that needs surgery

   A transient response to fluid, with blood pressure improving and then falling again, indicates continuing hemorrhage that will need surgical or interventional control. Fluid alone cannot fix it, and large volumes dilute clotting factors. Continue limited resuscitation, give blood if available, and transport rapidly.

3. Kehr sign occurs because the diaphragm shares sensory pathways with the shoulder through the:

   1. A. Phrenic nerve
   2. B. Vagus nerve
   3. C. Femoral nerve
   4. D. Intercostal nerves
   Show answer

   Answer: A. Phrenic nerve

   The phrenic nerve arises from C3 to C5, the same cord levels that supply sensation to the shoulder, so the brain misreads diaphragmatic irritation as shoulder pain. The vagus nerve carries visceral fibers but does not cause this referral.

4. After a crash, a hypotensive woman has lower abdominal pain and a strong urge to have a bowel movement. This symptom can result from:

   1. A. Urine leaking from a bladder rupture
   2. B. Normal anxiety after a crash
   3. C. Abdominal wall spasm
   4. D. Blood pooling in the pelvis
   Show answer

   Answer: D. Blood pooling in the pelvis

   Blood collecting in the deepest part of the peritoneal cavity (the rectouterine pouch) presses on the rectum and can cause an urge to defecate, which also occurs with a ruptured ectopic pregnancy. Do not let such patients strain on a toilet; treat for shock and transport. A bladder injury causes suprapubic pain and trouble voiding rather than a rectal urge, abdominal wall spasm does not cause hypotension, and anxiety does not explain the symptom with low blood pressure.

5. Cullen and Grey Turner signs are of limited use in the field mainly because they:

   1. A. Are seen mainly in children
   2. B. Point to bowel injury
   3. C. Take hours to develop
   4. D. Appear within seconds
   Show answer

   Answer: C. Take hours to develop

   Bruising from internal bleeding takes hours to track to the skin, so its absence early after injury means little. A patient can bleed to death from a liver or spleen injury before any discoloration appears.

6. A 31-year-old man hit the steering wheel and has right upper quadrant pain and right shoulder pain. P 118/min, BP 100/70 mmHg. You should suspect:

   1. A. Splenic injury with hemoperitoneum
   2. B. Liver injury with hemoperitoneum
   3. C. A right clavicle fracture
   4. D. An isolated rib contusion
   Show answer

   Answer: B. Liver injury with hemoperitoneum

   Blood under the right hemidiaphragm can refer pain to the right shoulder, and tachycardia with right upper quadrant pain suggests liver bleeding. The spleen is on the left and would refer pain to the left shoulder.

7. A splenic injury can bleed slowly at first and then rupture hours to days later because:

   1. A. A subcapsular bleed enlarges and bursts
   2. B. The spleen regrows torn tissue quickly
   3. C. Splenic blood clots far faster than liver
   4. D. The spleen bleeds when it is palpated
   Show answer

   Answer: A. A subcapsular bleed enlarges and bursts

   Blood can collect under the splenic capsule (a subcapsular hematoma), which holds it for a time; as the hematoma enlarges, the capsule can tear and release sudden, delayed hemorrhage hours to days later, so a patient with a left upper quadrant blow and normal early vital signs still needs evaluation. The spleen does not regrow torn tissue fast enough to matter. Splenic blood does not clot faster than blood from the liver; clotting depends on the patient, not the organ. Gentle palpation does not start splenic bleeding, although rough handling is avoided.

8. A 17-year-old who has infectious mononucleosis was tackled during a basketball game and now has left upper quadrant pain. You should be especially concerned because:

   1. A. The infection lowers his blood volume
   2. B. Mononucleosis shrinks the spleen
   3. C. The infection blocks the pain of injury
   4. D. An enlarged spleen ruptures more easily
   Show answer

   Answer: D. An enlarged spleen ruptures more easily

   Mononucleosis and other illnesses can enlarge the spleen beyond the protection of the ribs and make it fragile, so minor trauma can rupture it. The infection enlarges the spleen rather than shrinking it, does not by itself deplete blood volume, and does not blunt the pain response.

9. Which early finding most reliably suggests ongoing bleeding from a solid organ injury?

   1. A. Abdominal distension
   2. B. Periumbilical bruising
   3. C. Rising heart rate
   4. D. Absent bowel sounds
   Show answer

   Answer: C. Rising heart rate

   Tachycardia and other signs of compensated shock develop well before the abdomen visibly distends. The abdomen can hold several liters of blood with little change in girth, so distension is a late, unreliable sign.

10. Pancreatic injury is often missed early after blunt trauma because the pancreas:

    1. A. Lies just under the anterior wall
    2. B. Lies deep in the retroperitoneum
    3. C. Rarely bleeds since it is small
    4. D. Refers its pain to the right shoulder
    Show answer

    Answer: B. Lies deep in the retroperitoneum

    The pancreas lies across the spine behind the stomach, so early signs are vague and peritoneal signs develop slowly as enzymes leak. It is not just under the anterior wall, it is well vascularized and can bleed significantly, and its pain classically radiates to the back rather than to the right shoulder.

11. A 10-year-old was struck in the epigastrium by a hockey stick 2 days ago. He now has worsening upper abdominal pain radiating to the back and is vomiting. You should suspect:

    1. A. Acute appendicitis
    2. B. Kidney stone
    3. C. Bladder rupture
    4. D. Pancreatic injury
    Show answer

    Answer: D. Pancreatic injury

    A focused epigastric blow can crush the pancreas against the spine, and leaking enzymes cause pain radiating to the back that worsens over 1 to 2 days. Appendicitis classically causes right lower quadrant pain without a trauma history.

12. A 24-year-old was kicked in the flank and now has flank bruising, tenderness, and a palpable flank fullness. These findings suggest:

    1. A. A splenic capsule tear
    2. B. A urethral disruption
    3. C. A perirenal hematoma
    4. D. A bowel perforation
    Show answer

    Answer: C. A perirenal hematoma

    Blood collecting around an injured kidney in the retroperitoneum can produce flank ecchymosis, tenderness, and a palpable mass. A urethral tear causes blood at the meatus and inability to void, not a flank mass.

13. A 30-year-old was kicked in the right flank. He has flank tenderness and only faintly pink urine. P 112/min, BP 104/72 mmHg. How should the small amount of blood in his urine affect your thinking?

    1. A. It shows the kidney injury is minor and stable
    2. B. It does not exclude a severe kidney injury
    3. C. It means the blood is from the bladder
    4. D. It allows transport to any hospital
    Show answer

    Answer: B. It does not exclude a severe kidney injury

    The amount of blood in the urine correlates poorly with the severity of a renal injury: a shattered kidney or a torn renal pedicle may cause little or no hematuria, while a minor contusion can turn the urine red. His flank findings and tachycardia are the more important clues to retroperitoneal bleeding. Faint hematuria therefore does not show the injury is minor or stable. Urine color cannot locate the source in the field, and a direct flank blow points to the kidney, not the bladder. His heart rate is higher than his systolic pressure, a red criterion in the 2021 National Field Triage Guideline, so he belongs at a trauma center, not any hospital. (AUA Urotrauma Guideline 2017, amended 2020; 2021 National Guideline for the Field Triage of Injured Patients.)

14. A 52-year-old was struck by a car and has a fracture of the left eleventh and twelfth ribs posteriorly. You should be especially alert for injury to the:

    1. A. Left kidney and spleen
    2. B. Liver and the gallbladder
    3. C. Bladder and urethra
    4. D. Appendix and cecum
    Show answer

    Answer: A. Left kidney and spleen

    The lower left posterior ribs overlie the spleen and upper pole of the left kidney, so fractures there suggest injury beneath them. The liver and gallbladder lie on the right.

15. A 23-year-old has a liver laceration after a crash. Which feature makes liver bleeding particularly difficult to control?

    1. A. A capsule that prevents clot formation
    2. B. Poor blood flow through its tissue
    3. C. Dual arterial and portal blood supply
    4. D. The liver lies outside the peritoneum
    Show answer

    Answer: C. Dual arterial and portal blood supply

    The liver receives blood from the hepatic artery and the portal vein and drains through large hepatic veins into the vena cava, so lacerations bleed heavily from several sources. Liver blood can clot, although coagulopathy develops in prolonged shock.

16. A 35-year-old was assaulted and has right upper quadrant tenderness, a pulse of 96/min, and a BP of 132/84 mmHg. The most accurate interpretation is that:

    1. A. Liver injury is still possible
    2. B. Liver injury has been ruled out
    3. C. The tenderness is from the skin
    4. D. He is in decompensated shock
    Show answer

    Answer: A. Liver injury is still possible

    A healthy young adult can lose a large volume of blood while keeping a normal pulse and blood pressure, so right upper quadrant tenderness after an assault keeps liver injury on the list and calls for serial reassessment and hospital evaluation. Normal vital signs cannot rule out a solid organ injury. Blaming the tenderness on the skin is a guess that can miss a bleeding liver. A BP of 132/84 mmHg with a pulse of 96/min is not decompensated shock, which would show hypotension and signs of poor perfusion.

17. A liver laceration can leak bile as well as blood. Bile in the peritoneal cavity causes:

    1. A. Rapid clotting of blood
    2. B. Immediate bowel blockage
    3. C. Painless abdominal swelling
    4. D. Chemical peritonitis
    Show answer

    Answer: D. Chemical peritonitis

    Bile is irritating to the peritoneum and produces chemical peritonitis, which adds pain and inflammation to the bleeding. Bile does not speed clotting, and its effect is painful rather than painless.

18. A 44-year-old with a suspected splenic injury has a pulse of 132/min, a BP of 84/56 mmHg, and cool, pale skin. The definitive treatment he most likely needs is:

    1. A. IV fluid boluses until his BP is normal
    2. B. Surgery or embolization at a trauma center
    3. C. Observation with a repeat exam in 6 hours
    4. D. Analgesia and an abdominal binder on scene
    Show answer

    Answer: B. Surgery or embolization at a trauma center

    An unstable patient with a solid organ injury needs surgical control or interventional radiology, so rapid transport to a trauma center is the priority. Fluid to a normal blood pressure can dilute clotting factors and dislodge clots.

19. A patient whose spleen was removed after trauma is at lifelong increased risk of:

    1. A. Low platelet counts
    2. B. Gallstones
    3. C. Severe infection
    4. D. Chronic liver failure
    Show answer

    Answer: C. Severe infection

    Without a spleen, the body clears encapsulated bacteria such as pneumococcus poorly, so asplenic patients are vaccinated and treated quickly for fever. Removing the spleen tends to raise the platelet count rather than lower it, and it does not cause gallstones or liver failure.

20. The term hemoperitoneum refers to:

    1. A. Blood in the peritoneal cavity
    2. B. Air within the peritoneal cavity
    3. C. Blood in the urinary bladder
    4. D. Bile within the gallbladder
    Show answer

    Answer: A. Blood in the peritoneal cavity

    Hemoperitoneum is free blood in the peritoneal cavity, most often from a liver or spleen injury, and it is the fluid that FAST looks for. Air in the cavity is pneumoperitoneum, a sign of hollow organ perforation.

21. A 60-year-old was in a crash and has no abdominal pain but has a femur fracture and is hypotensive with clear lung sounds. You should consider that he may also have:

    1. A. Isolated neurogenic shock
    2. B. A simple pneumothorax
    3. C. Hypothermia from exposure
    4. D. Occult abdominal bleeding
    Show answer

    Answer: D. Occult abdominal bleeding

    An unexplained shock state demands a search of the chest, abdomen, pelvis, and thighs, and the painful femur can distract from abdominal findings. Neurogenic shock would require spinal cord injury and is a diagnosis of exclusion in trauma.

22. Which description best fits a subcapsular hematoma of the liver or spleen?

    1. A. Blood free in the peritoneal cavity
    2. B. Blood trapped under the organ's capsule
    3. C. Blood spread through the organ's deep tissue
    4. D. Blood in the fat around the kidney
    Show answer

    Answer: B. Blood trapped under the organ's capsule

    A subcapsular hematoma is bleeding contained beneath the fibrous capsule of a solid organ. It may remain stable or later rupture into the peritoneal cavity, causing delayed hemorrhage. Free intraperitoneal blood has already escaped the capsule, bleeding within the organ's substance is an intraparenchymal hematoma, and blood in the fat around the kidney lies outside its capsule.

23. A 29-year-old with a liver injury reports increasing abdominal pain, and his abdomen is now firm. His pulse has risen from 100 to 128/min. The best interpretation is:

    1. A. His pain is improving
    2. B. Shock is resolving now
    3. C. Bleeding is continuing
    4. D. The liver has sealed itself
    Show answer

    Answer: C. Bleeding is continuing

    A rising heart rate with increasing pain and abdominal firmness signals ongoing hemorrhage and worsening shock. This change calls for faster transport and trauma team notification, not continued observation.

24. The kidneys are well protected; a blunt kidney injury is therefore a clue that the patient:

    1. A. Likely absorbed a large amount of force
    2. B. Probably has no other internal injuries
    3. C. Needs outpatient follow-up care
    4. D. Has an injury limited to the skin
    Show answer

    Answer: A. Likely absorbed a large amount of force

    Because the kidneys are deep and cushioned, a renal injury implies significant energy transfer, so look for associated injuries to the spleen, liver, ribs, and spine. A kidney injury does not imply the patient is otherwise uninjured.

25. The adult abdomen can conceal a large blood loss mainly because the peritoneal cavity:

    1. A. Distends visibly with small losses
    2. B. Can hold several liters of blood
    3. C. Holds at most about 500 mL
    4. D. Clots blood as soon as it pools
    Show answer

    Answer: B. Can hold several liters of blood

    The peritoneal cavity and retroperitoneum together can hold a large part of the circulating volume before the abdomen looks distended. Girth changes little even with liters of blood, the space holds far more than 500 mL, and pooled blood does not clot fast enough to stop the bleeding.