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Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED) A 56 y/o M pt involved in a motor vehicle crash is brought to the ED of a rural critical access facility. He complains of neck pain, SOB, and diffuse abd pain. His GCS is 15. His VS: BP 98/71, HR 125, RR 26, SpO2 94% on high-flow O2 via NRB mask. Which of the following is the priority intervention for this patient? - correct answer Expedite transfer to the closest trauma center Which of the following considerations is the most important when caring for a geriatric trauma pt? - correct answer a pertinent medical hx is crucial Following a review of recent drills and a real disaster event, a hospital has identified deficiencies and is taking steps to minimize the impact of a future disaster. Which phase of the disaster life cycle does this describe? - correct answer Mitigation EMS brings a pt who fell while riding his bicycle. Using the American College of Surgeons screening guidelines, which assessment finding would prompt the RN to prepare the pt for a radiologic spine clearance? - correct answer Alcohol All tools and guidelines require the patient to be awake, alert, not under the influence of any substances, and without neurologic abnormalities What is the effect of hypothermia on the oxyhemoglobin dissociation curve? - correct answer hemoglobin does not readily release O2 for use by the tissues Which of the following is a component of the trauma triad of death? - correct answer acidosis EMS brings a pt from MVC. VS: BP 90/49, HR 48, RR 12, temp 97.2F (36.2 C). The pt exhibits urinary incontinence and priapism. These assessment findings are most consistent with which of the following types of spinal cord injury? - correct answer Complete Which of the following is an expected finding in a pt with a tube thoracstomy connected to a chest drainage system? - correct answer flucuation in the water seal chamber During the primary survey of an unconscious pt with multi-system trauma, the nurse notes snoring respirations. What priority nursing interventions should be preformed next? - correct answer insert an oropharyngeal airway if there is no gag reflex A 35 y/o M presents with facial trauma after being struck in the face with a baseball. A teardrop-shaped left pupil is noted on exam. What type of injury is suspected? - correct answer globe rupture A trauma pt is restless and repeatedly asking "where am i?" VS upon arrival: BP 110/60, HR96, RR 24. Her skin is cool and dry. Current VS are BP 104/84, HR 108, RR 28. The pt is demonstrating s/sx of which stage of shock? - correct answer compensated An unresponsive trauma pt has an oropharygeal airway in place, shallow and labored respirations, and dusky skin. The trauma team has administered medications for drug-assisted

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED) intubation and attempted intubation but was unsuccessful. What is the most appropriate immediate next step? - correct answer ventilate with a bag mask device When is the tertiary survey completed fora trauma pt? - correct answer within 24 hrs of trauma An intubated and sedated pt in the ED has multiple extremity injuries with the potential for causing compartment syndrome. What is the most reliable indication of compartment syndrome in a patient who is unconscious? - correct answer pressure Which of the following is possible complication of positive-pressure ventilation? - correct answer worsening pneumothorax the most reassuring finding for a male pt with hip pain after a fall is which of the following? - correct answer pelvic stability Which of the following pulse pressures indicate early hypovolemic shock? - correct answer narrowed Patients with a crush injury should be monitored for which of the following conditions? - correct answer dysrhythmias Tearing of the bridging veins is most frequently associated with which brain injury? - correct answer subdural hematoma A 20 y/o M presents to the ED complaining of severe lower abd pain after landing hard on the bicycle cross bars while preforming an aerial BMX maneuver. Secondary assessment reveals lower abd tenderness and scrotal ecchymosis. Which of the following orders would the RN question? - correct answer straight cath for urine sample You are caring for a pt who was involved in a MVC and is 32 weeks pregnant. Findings of your secondary survey include abd pain on palpation, fundal ht at the costal margin, and some dark bloody show. Varying accelerations and decelerations are noted on cariocgraphy. These findings are most consistent with which of the following? - correct answer placental abruption Which of the following is true about the log-roll? - correct answer it can worsen cord damage from an unstable spinal injury All of these are considered a critical communication point in trauma care EXCEPT which of the following? - correct answer defusings What bedside monitoring parameters are used to assess for adequacy of O2 and effectiveness of ventilation? - correct answer pulse oximetry and capnography Caregivers carry in a 2 y/o into the ED who fell out of a second-story window. The pt is awake and crying with increased work of breathing and pale skin. Which of the following interventions

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED) has the highest priority? - correct answer padding the upper back while stabilizing the cervical spine Which of the following injuries is LEAST likely to be promptly identified? - correct answer bowel A pt is brought to the ED of a rural hospital following a high-speed MVC. When significant abd and pelvic injuries are noted in the primary survey, which of the following is the priority interventions? - correct answer Initiate transfer to a trauma center A pt with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs? - correct answer bardycardia and absent motor function below the level of injury a 37 y/o F has a deformity of the L wrist after a fall. She is reluctant to move her hand due to pain. Which of the following is the most appropriate intervention? - correct answer apply splint and elevate above the level of the heart which of the following occurs during the third impact of a motor vehicle crash? - correct answer the aorta is torn at its attachment with the ligamentum arteriosum a 5 y/o child presents to the ED with bruises to the upper arm and buttocks in various stages of healing and multiple small, clean, round burns to the back. There are no abnormalities found based on the pediatric assessment triangle or primary survey. Which of the following is the priority survey. Which of the following is the priority nursing intervention? - correct answer Report your suspicion of maltreatment in accordance with local regulations Why is a measure of serum lactate obtained in the initial assessment of a trauma patient? - correct answer to guage end-organ perfusion and tissue hypoxia A pt with a lower extremity fracture complains of severe pain and tightness in his calf, minimally by pain medications. Which of the following is the priority nursing intervention? - correct answer elevating the extremity to the level of the heart What factor contributes most to the kinetic energy of a body in motion? - correct answer velocity An elderly patient with a history of anticoagulant use presents after a fall at home today. She denies any loss of consciousness. She has a hematoma to her forehead and complains of headache, dizziness, and nausea. What is the most likely cause of her symptoms? - correct answer subdural hematoma a pt has been in the ED for several hrs waiting to be admitted. He sustained multiple rib fractures and a femur fracture after a fall. He has been awake, alert, and complaining of leg pain. His wife reported that he suddenly became anxious and confused. Upon reassessment, the pt is restless with respiratory distress and petechiae to his neck. The pt is exhibiting s/sx

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED) most commonly associated with which of the following conditions? - correct answer fat embolism Which of the following is a late sign of increased intracranial pressure? - correct answer Late signs of increased intracranial pressure include: dilated nonreactive pupils, unresponsive to verbal or painful stimuli, abnormal motor posturing, and Cushing response (widening pulse pressure, reflex bradycardia, decreased respiratory effort) a 49 y/o restrained driver involved in a MVC presents to the trauma center complaining of abd, pelvic, and bilateral lower extremity pain. VS are stable. The nurse can anticipate all of these after a negative FAST exam EXCEPT which of the following? - correct answer serial FAST exams Which of the following is NOT considered goal-directed therapy for cardiogenic shock? - correct answer pericardiocentesis The trauma nurse knows that placing a bariatric patient in a ramped position providers better visualization during the insertion of which device? - correct answer endotracheal tube which of the following assessment findings differentiates a tension pneumothorax from a simple pneumothorax? - correct answer increased work of breathing Assessment findings associated with tension pneumothorax include anxiety, severe restlessness, severe respiratory distress, and absent breath sounds on the injured side if a pt has received multiple transfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation? - correct answer calcium Which of the following is NOT considered a benefit of debriefings? - correct answer identifying individuals who made mistakes during the traumatic event You are treating a 27 y/o M in respiratory distress who was involved in a house fire. Calculating TBSA burned is deferred due to the need for emergent intubation. At what rate should you begin fluid resuscitation? - correct answer 500 mL/hr Which of the following is most likely to contribute to inadequate oxygenation and ventilation? - correct answer advanced age Which of the following patients warrants referral to a burn center? - correct answer a 52 y/o diabetic male with a partial thickness burn to the left lower leg A patient arrives with a large open chest wound after being assaulted with a machete. Prehospital providers placed a nonporous dressing over the chest wound and taped it on three sides. he is now showing signs of anxiety, restlessness, severe respiratory distress, cyanosis and decreasing blood pressure. Which of the following is the MOST appropriate immediate intervention? - correct answer dressing removal

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED) EMS arrives with the intoxicated driver of a car involved in a MVC. EMS reports significant damage to the drivers side of the car. The pt is asking to have the cervical collar removed. When it is appropriate to remove the cervical collar? - correct answer after a physical examination if the pt has no radiologic abnormalities on CT Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage? - correct answer MARCH A branch of mechanics (energy transfer) that refers to motion and does not consider the concepts of force and mass of the object or body. - correct answer What is kinematics? A body at rest will remain at rest. A body in motion will remain in motion until acted on by an outside force. - correct answer What is Newton's First Law? Energy can neither be created nor destroyed. It is only changed from one form to another. - correct answer What is the Law of Conservation of Energy? Force equals mass multiplied by acceleration of deceleration. - correct answer What is Newton's Second Law? KE equals 1/2 the mass (M) multiplied by the velocity squared. - correct answer What is kinetic energy (KE)? A = Airway with simultaneous cervical spine protection B = Breathing C = Circulation D = Disability (neurologic status) E = Expose/Environmental controls (remove clothing and keep the patient warm) - correct answer What is the Mnemonic for the Initial Assessment? F = Full set of VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family presence G = Give comfort measures (verbal reassurance, touch, and pharmacologic and nonpharmacologic management of pain). H = Hx and Head-to-toe assessment I = Inspect posterior surfaces - correct answer What is the Mnemonic for the Secondary Assessment? Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at the fifth intercostal space at the anterior axillary line. - correct answer Where do you listen to auscultate breath sounds?

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• Tracheal deviation
  • JVD - correct answer What are the late signs of breathing compromise?
• AMS
  • Cyanosis, especially around the mouth
  • Asymmetric expansion of chest wall
  • Paradoxical movement of the chest wall during inspiration and expiration
  • Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing
  • Sucking chest wounds
  • Absent or diminished breath sounds
  • Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated
  • Anticipate definitive airway management to support ventilation. - correct answer What are signs of ineffective breathing? A tight-fitting nonrebreather mask at 12-15 lpm. - correct answer Upon initial assessment, what type of oxygen should be used for a pt breathing effectively?
• Insert 2 large caliber IV's
  • Administer warmed isotonic crystalloid solution at an appropriate rate - correct answer What intervention should be done if a pt presents with effective circulation?
• Tachycardia
  • AMS
  • Uncontrolled external bleeding
  • Pale, cool, moist skin
  • Distended or abnormally flattened external jugular veins
  • Distant heart sounds - correct answer What are signs of ineffective circulation?
• Control any uncontrolled external bleeding by:
  • Applying direct pressure over bleeding site
  • Elevating bleeding extremity
  • Applying pressure over arterial pressure points
  • Using tourniquet (last resort).

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution
• Use warmed solution
• Use pressure bags to increase speed of IVF infusion
• Use blood administration tubing for possible administration of blood
• Use rapid infusion device based on protocol
• Use NS 0.9% in same tubing as blood product
• IV = surgical cut-down, central line, or both.
• Blood sample to determine ABO and Rh group
• IO in sternum, legs, arms or pelvis
• Administer blood products
• PASG (without interfering with fluid resuscitation) - correct answer What are the interventions for Effective/Ineffective Circulation? DISABILITY A = Alert V = Verbal P = Pain U = Unresponsive
• GCS
• PERRL?
• Determine presence of lateralizing signs including:
• Unilateral deterioration in motor movements or unequal pupils
• Symptoms that help to locate area of injury in brain - correct answer How do you assess Mnemonic "D"?
• If assessment indicates a decreased LOC, conduct further investigation during secondary focused assessments
• If pt is not alert or verbal, continue to monitor for any compromise to ABC's
• If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation. - correct answer What are the interventions for Disability?

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• Remove clothing
  • Ensure appropriate decontamination if exposed to hazardous material
  • Keep pt warm
  • Keep clothing for evidence - correct answer What is assessed and intervened for Expose/Environmental Controls? FULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE
  • ABCDE should be completed
  • Labs, X-rays, CT, Foley,
  • Family Presence - correct answer What is the first thing assessed under the Secondary Assessment? GIVE COMFORT MEASURES
  • Talking to pt
  • Pharmacologic/Nonpharmacologic pain management
  • Observe for physical signs of pain - correct answer What is the second thing assessed under the Secondary Assessment? HISTORY / HEAD-TO-TOE ASSESSMENT
  • MIVT
  • M = Mechanism of injury
  • I = Injuries sustained
  • V = Vital Signs
  • T = Treatment
  • Pt generated information
  • PMH
  • Head-to-toe assessment - correct answer What is assessed under the Mnemonic "H"? INSPECT POSTERIOR SURFACES
  • While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and posterior thighs.
  • Palpate vertebral column for deformity and areas of tenderness

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• Assess rectum for presence/absence of tone, presence of blood - correct answer What is assessed under the Mnemonic "I"? Reassess:
• Primary survey,
• VS
• Pain
• Any injuries - correct answer What she be done after the Secondary Assessment?
• AMS
• LOC
• Neurologic injury
• Spinal Cord Injury
• Intracranial Injury
• Blunt trauma
• Pain caused by rib fractures
• Penetrating Trauma
• Preexisting hx of respiratory diseases
• Increased age - correct answer What are factors that contribute to ineffective ventilation? LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents - correct answer What medications are used during intubation? PREPARATION:
• gather equipment, staffing, etc. PREOXYGENATION:
• Use 100% O2 (prevent risk of aspiration). PRETREATMENT:

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• Decrease S/E's of intubation PARALYSIS WITH INDUCTION:
• Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING:
• Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF
• Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts.
• After intubation, inflate the cuff
• Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT:
• Secure ET tube
• Set ventilator settings
• Obtain Chest x-ray
• Continue to medicate
• Recheck VS and pulse oxtimetry - correct answer What are the Rapid Sequence Intubation Steps? A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult. - correct answer What is a Combitube? Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords. - correct answer What is a Laryngeal Mask Airway? Percutaneous transtracheal ventilation. (temporary) Complications include:
• inadequate ventilation causing hypoxia

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• hematoma formation
• esophageal perforation
• aspiration
• thyroid perforation
• subcutaneous emphysema - correct answer What is Needle Cricothyrotomy Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated. Complications include:
• Aspiration
• Hemorrhage or hematoma formation or both
• Lac to trachea or esophagus
• Creation of a false passage
• Laryngeal stenosis - correct answer What is Surgical Cricothyrotomy?
• Visualization of the chords
• Using bronchoscope to confirm placement
• Listening to breath sounds over the epigastrum and chest walls while ventilating the pt
• CO2 detector
• Esophageal detection device
• Chest x-ray - correct answer How do you confirm ET Tube/Alternative Airway Placement? Observe:
• mental status
• RR and pattern
• chest wall symmetry
• any injuries
• patient's skin color (cyanosis?)

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• JVD or tracheal deviation? (Tension pneumothorax) - correct answer How do you inspect the chest for adequate ventilation? Absence of BS:
• Pneumothorax
• Hemothorax
• Airway Obstruction Diminished BS:
• Splinting or shallow BS may be a result of pain - correct answer What are you looking for when auscultating lung sounds? Dullness:
• hemothorax Hyperresonance
• Pneumothorax - correct answer What are you looking for when percussing the chest?
• Tenderness
• Swelling
• subcutaneous emphysema
• step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax. - correct answer What are you looking for when palpating the chest wall, clavicles and neck? D - Displaced tube O - Obstruction: Check secretions or pt biting tube P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing - correct answer What is the DOPE mnemonic? Most common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn).

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED) Some causes:

• Blood loss
• Burns, etc. - correct answer Explain Hypovolemic Shock. Syndrome that results from ineffective perfusion caused by ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes:
• MI
• Blunt cardiac injury
• Mitral valve insufficiency
• dysrhythmias
• Cardiac Failure - correct answer Explain Cardiogenic Shock. Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself. Some causes:
• Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume).
• Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium.
• Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock - correct answer Explain Obstructive Shock. Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region. Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock.

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED) Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities. - correct answer Explain Distributive Shock. As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP. - correct answer What is vascular response? Renal ischemia activates release of renin. Kidneys do not receive adequate blood supply, renin is release into circulation. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. Angiotensin-converting enzyme from the lungs converts into angiotensin II. Angiotensin II causes:

• Vasoconstriction of arterioles and some veins
• Stimulation of sympathetic nervous system
• Retention of water by kidneys
• Stimulation of release of aldosterone from the adrenal cortex (sodium retention hormone) *Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion. - correct answer What is renal response? When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. Epi stimulates receptors in heart to increase force of cardiac contraction (positive inotropy) and increase HR (positive chronotropy) to improve cardiac output, BP and tissue perfusion.

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED) Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol. Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar. Cortisol also causes renal retention of water and sodium, a compensatory mechanism to conserve body water. - correct answer Explain adrenal gland response. Liver can store excess glucose as glycogen. As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose. In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas. - correct answer Explain Hepatic Response. Tachypnea happens for 2 reasons:

1. Maintain acid-base balance
2. Maintain increased supply of oxygen

• Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs to increase rate of ventilation. Increased RR is an attempt to correct acidosis + augments oxygen supply to maximize oxygen delivery to alveoli. - correct answer Explain Pulmonary Response. Shock uncompensated or irreversible stages will cause compromises to most body systems.

• Inadequate venous return
• inadequate cardiac filling
• decreased coronary artery perfusion
• Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage. - correct answer Explain Irreversible Shock. (Use Initial Assessment) and then: Inspect:

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• LOC
• Rate and quality of respirations
• External bleeding?
• Skin color and moisture
• Assess jugular veins and peripheral veins Auscultate:
• BP
• Pulse pressure
• Breath sounds
• Heart sounds
• Bowel sounds Percuss:
• Chest and abdomen Palpate:
• Central pulse (carotid or femoral)
• Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse
• Palpate peripheral pulses
• Palpate skin temp and moisture Diagnostic Procedures:
• Xrays and other studies
• Labs Planning and Implementation
• Oxygen
• IV's with warmed replacement fluids
• Control external bleeding with direct pressure
• Elevate LE's
• NGT

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• Foley
• Monitor and pulse oximeter
• Monitor for development of coagulopathies
• Surgery? - correct answer How would you assess someone in hypovolemic shock?

1. Brain
2. CSF
3. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful. Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP. - correct answer ICP is a reflection of what three volumes? What happens when one increases?

• Headache
• N/V
• Amnesia regarding events around the injury
• Altered LOC
• Restlessness, drowsiness, changes in speech, or loss of judgement - correct answer What are the early signs and symptoms of increased ICP?
• Dilated, nonreactive pupil
• Unresponsiveness to verbal or painful stimuli
• Abnormal motor posturing patterns
• Widening pulse pressure
• Increased systolic blood pressure

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• Changes in RR and pattern
• Bradycardia - correct answer What are the late observable signs of symptoms of increased ICP? Triad of progressive HTN, bradycardia and diminished respiratory effort. - correct answer What is Cushing's phenomenon or Cushing's Reflex?

1. Uncal herniation
2. Central or transtentorial herniation - correct answer What are the two types of herniation that occurs with ICP? Because of uncontrolled increases in ICP. S/E's

• Unilateral or bilateral pupillary dilation
• AsyDimmetric pupillary reactivity
• Abnormal motor posturing
• Other evidence of neurologic deterioration - correct answer Why does herniation occur? What are the symptoms? The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes.
• correct answer Define uncal herniation. A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. - correct answer Define central or transtentorial herniation. Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. Also: meningitis or encephalitis or brain abscess - correct answer Disruptions of the bony structures of the skull can result in what? GCS 13- 15 - correct answer Define Minor Head Trauma. Postresuscitative state with GCS 9-13. - correct answer Define Moderate Head Trauma

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED) Postresuscitative state with GCS score of 8 or less. - correct answer Define Severe Head Trauma. A temporary change in neurologic function that may occur as a result of minor head trauma. S/S:

• Transient LOC
• H/A
• Confusion and disorientation
• Dizziness
• N/V
• Loss of memory
• Difficulty with concentration
• Irritability
• Fatigue - correct answer What is a concussion and its signs and symptoms?
• Persistent H/A
• Dizziness
• Nausea
• Memory impairment
• Attention deficit
• Irritability
• Insomnia
• Impaired judgement
• Loss of libido
• Anxiety
• Depression - correct answer What are the signs and symptoms of postconcussive syndrome? (DAI) is widespread, rather than localized, through the brain. Diffuse shearing, tearing and compressive stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain. S/S:

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• Immediate unconsciousness
• mild DAI, coma = 6-24 hrs
• severe DAI, coma = weeks/months or persistent vegetative state
• Elevated ICP
• Abnormal posturing
• HTN
• Hyperthermia
• Excessive sweating because of autonomic dysfunction
• Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits - correct answer What is diffuse axonal injury and its signs and symptoms? A common focal brain injury in which brain tissue is bruised and damaged in a local area. Mainly located in frontal and temporal lobes. May cause hemorrhage, infarction, necrosis and edema. Max effects of bleeding & edema peak 18-36 post injury. S/S:
• Alteration in LOC
• Behavior, motor or speech deficits
• Abnormal motor posturing
• Signs of increased ICP - correct answer What is a cerebral contusion and its S/S? Results when a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accumulates rapidly:
• Compression of underlying brain
• rapid increase in ICP
• Decreased CBF
• Secondary brain injury

• Usually requires surgical intervention S/S:

• Transient LOC
• Lucid period lasting a few minutes to several hours

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• Rapid deterioration in neurologic status
• Severe H/A
• Sleepiness
• Dizziness
• N/V
• Hemiparesis or hemiplegia on opposite side of hematoma
• Unilateral fixed and dilated pupil on same side of hematoma - correct answer What is an epidural hematoma and its S/S? A focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic. Acute pt's hematoma manifest 48 hrs post injury S/S:
• Altered LOC or steady decline in LOC
• S/S of increased ICP
• Hemiparesis or hemiplegia on opposite side of hematoma
• Unilateral fixed and dilated pupil on same side of hematoma Chronic pt's " " up to 2 wks post injury
• H/A
• Progressive decrease in LOC
• Ataxia
• Incontinence
• Sz's - correct answer What is a subdural hematoma and its S/S? Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S:

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• Progressive and often rapid decline in LOC
• H/A
• Signs of increasing ICP
• Pupil abnormalities
• Contralateral hemiplegia - correct answer What are intracerebral hematoma's and its S/S?
• H/A
• Possible decreased LOC - correct answer What are the S/S of a linear skull fx?
• H/A
• Possible decreased LOC
• Possible open fx
• Palpable depression of skull over the fx site - correct answer What are the S/S of a depressed skull fx?
• H/A
• Altered LOC
• Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum)
• Facial nerve (VII) palsy
• CSF rhinorrhea or otorrhea - correct answer What are the S/S of a basilar skull fx? (Initial assessment) INSPECTION:
• Assess airway
• RR, pattern and effort
• Assess pupil size and response to light
• Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome
• Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates
• Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome
• Widely dilated pupil occasionally occurs w/direct trauma to globe of eye

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• Determine if pt uses eye meds
• Abnormal posturing?
• Inspect craniofacial area for ecchymosis/contusions
• Periorbital ecchymosis
• Mastoid's process ecchymosis
• Blood behind tympanic membrane
• Inspect nose and ears for drainage
• Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF
• If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light oute - correct answer How would you assess a pt with a cranial injury?
• Visual disturbances
• Pain
• Redness and ecchymosis of the eye
• Periorbital ecchymosis
• Increased intraocular pressure - correct answer What are signs of a serious eye injury? Accumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). S/S:
• Blood in anterior chamber
• Deep, aching pain
• Mild to severe diminished visual acuity
• Increased intraocular pressure - correct answer What is hyphema and its S/S? Chemical injuries require immediate intervention if it is to be preserved. S/S:
• Pain
• Corneal Opacification

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• Coexisting chemical burn and swelling of lids - correct answer What are s/s of chemical burns to the eye?
• Marked visual impairments
• Extrusion of intraocular contents
• Flattened or shallow anterior chamber
• Subconjunctival hemorrhage, hyphema
• Decreased intraocular pressure
• Restriction of extraocular movements - correct answer What are S/S of penetrating trauma/open or ruptured globe?
• Diplopia (double vision)
• Loss of vision
• Altered extraocular eye movements
• Enophthalmos (displacement of the eye backward into the socket)
• Subconjunctival hemorrhage or ecchymosis of the eyelid
• Infraorbital pain or loss of sensation
• Orbital bony deformity - correct answer What are the S/S of orbital fracture (orbital blowout fracture)? Transverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. S/S:
• Slight swelling of maxillary area
• Possible lip lac's or fractured teeth
• Independent movement of the maxilla from rest of face
• Malocclusion - correct answer What is LeFort I fracture and its S/S? Pyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. S/S:

Exam, TNCC final exam test open book OE COMPLETE QUESTIONS AND ANSWERS (VERIFIED)

• Massive facial edema
• Nasal swelling w/obvious fx of nasal bones
• Malocclusion
• CSF rhinorrhea - correct answer What is LeFort II fracture and its S/S? Complete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible. S/S:
• Massive facial edema
• Mobility and depression of zygomatic bones
• Ecchymosis
• Anesthesia of the cheek
• Diplopia
• Open bite or malocclusion
• CSF rhinorrhea - correct answer What is LeFort III fracture and its S/S?
• Malocclusion
• Inability to open the mouth (trismus)
• Pain, especially on movement
• Facial asymmetry and a palpable step-off deformity
• Edema or hematoma formation at the fracture site
• Blood behind, ruptured, tympanic membrane
• Anesthesia of the lower lip - correct answer What are the mandibular fracture S/S?
• Dyspnea
• Hemoptysis (coughing up blood)
• Subcutaneous emphysema in neck, face, or suprasternal area
• Decreased or absent breath sounds
• Penetrating wounds or impaled objects
• Pulsatile or expanding hematoma