Neurogenic Shock and Trauma Management, Exams of Nursing

Download Neurogenic Shock and Trauma Management and more Exams Nursing in PDF only on Docsity! TNCC Written Exam, Test Prep, Trauma Nursing Process - TNP - TNCC 9th Ed, Trauma Nursing Core Course (TNCC)- 9th edition. Questions and Detailed Answers. What is the best measure of the adequacy of cellular perfusion and helps predict the outcome of resuscitation? - ANSBase deficit used in conjunction with serum lactate Will hypocapnia cause vasoconstriction or vasodilation, especially in the cerebral vasculature? - ANSVasoconstriction What results from tissue hypo perfusion and oxygen deficit? - ANSMetabolic acidosis What type of shock results in generalized vasodilation? - ANSNeurogenic shock Spinal cord injuries at C3-C5 causes loss of what nerves function, resulting in what? - ANSPhrenic nerve; paralyzed diaphragm and inability to breath Extremity elevation AT the level of the heart is beneficial for what type of injury? - ANSCompartment Syndrome What is a high risk of frostbite? - ANSThrombus formation What two medications can be administered to maintain perfusion after a frostbite injury along with rewarming? - ANSTissue plasminogen activator or non steroidal anti- inflammatory medication (NSAIDS) An rise in diastolic blood pressures is a sign of increasing what? - ANSPeripheral resistance What position will benefit the airway and work of breathing for the bariatric patient? - ANSReverse Trendelenburg Which phase of a blast results from flying debris, projectiles, and bomb fragments causing lacerations or penetrating injuries? - ANSSecondary Phase What phase of a blast results from any explosion-related illness or injury including hyperglycemia, hypertension, angina, asthma, COPD, or sepsis? - ANSQuaternary Phase What phase of a blast results from individuals being thrown by the blast and impacting walls, ground, or any hard object? - ANSTertiary Phase What phase of a blast results from impact of the over and under pressurization wave with body surfaces. Injuries include blast lung, tympanic membrane rupture, abdominal hemorrhage, globe rupture, and mild traumatic brain injury? - ANSPrimary Phase Signs of what include muscle pain or weakness, dark red or brown urine, general weakness or malaise, and elevated creatinine kinase levels? - ANSRhabdomyolosis Signs of what include anxiety, pleuritic chest pain, dyspnea, hypoxemia, hemoptysis, cough, orthopnea, adventitious lung sounds, decreased lung sounds, jugular vein distention, or hypotension? - ANSPulmonary Embolus Signs of what include headache, nausea and vomiting, amnesia, behavioral changes, altered level of consciousness? - ANSIncreased intracranial pressure Signs of what include asymmetric pupillary reactivity, unilateral dilation, widening pulse pressure, abnormal motor posturing, bradycardia, and decreased respiratory effort? - ANSLate signs of increased ICP with Herniation Syndrome What is caused by the tear of the bridging veins or middle meningeal artery? - ANSSubdural and Epidural Hematoma Affect concentration, memory, sleep, mode, and libido. Causes headaches, dizziness and nausea. - ANSPostconcussive Syndrome/ Mild Traumatic Brain Injury Signs and symptoms similar to early signs of increased ICP but do not worsen. - ANSPostconcussive Syndrome/ Mild Traumatic Brain Injury Cerebral Perfusion Pressure = ______-______ - ANSMAP - ICP What is the range for CO2 to maximize perfusion? - ANS35-45 Does hypoventilation cause dilation or constriction? Increase or decrease ICP? - ANSDilation and increase in ICP due to high CO2 Hyperventilation cause dilation or constriction? - ANSConstriction d/t low CO2 Pupils with pressure on cranial nerve - ANSFixed and dilated Pupils with opiates vs stimulants - ANSsmall; large Pupils with anticholinergics such as atropine, ipratropium, and scopolamine - ANSlarge Sluggish reaction of pupils is an early sign of what? - ANSIncreasing ICP Glasgow Coma Score with Mild, Moderate, and Severe TBI - ANSMild = 13-15 Moderate = 9-12 Urine Output goals for fluid replacement therapy - ANS0.5 mL/kg (30-50mL/hr) Disaster Definition - ANSA sudden calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic losses that exceed the community's or society's ability to cope using its own resources. Mitigation - ANSA foundation to limit the potential impact of a disaster Triage colors and meanings: - ANSGreen - minor, walking wounded Yellow - delayed Red - immediate Black - expectant, deceased When should the decision to transfer be made? - ANSWhen the patient's needs outweigh the capabilities of your facility Tertiary care facility, teaching hospital, comprehensive care from resuscitation or rehabilitation, research, injury prevention. - ANSLevel 1 Trauma Center Trauma rescucitation and definitive trauma care. Specialty and rehabilitation care may not be as comprehensive, may not conduct research. - ANSLevel 2 Trauma Center Provides ATLS assessment, intervention, resuscitation and emergency surgery. Generally does not accept transfers. - ANSLevel 3 Trauma Center Provides ATLS assessment, intervention, and resuscitation. May be in a remote area, has 24 hour physician and NP coverage. - ANSLevel 4 Trauma Center Greatest risk to the patient during interfaculty transfer/transport? - ANSLoss of airway and respiratory compromise What survey is a complete exam within 24 hours of arrival and identified injuries missed during primary assessment, reviews radiology studies, orders more studies, and assesses for hidden injuries? - ANSTertiary Survey Stages of shock - ANS1. Compensatory Shock 2. Decompensatory Shock (progressive, hypotensive) 3. Irreversible Shock Anxiety, confusion, restlessness, narrowing pulse pressure, tachycardia, bounding pulse, and decreasing urinary output are signs of what? - ANSCompensated Shock Decreased level of consciousness, hypotension, narrowed pulse pressure, tachycardia with weak pulse, tachypnea, and cool, clammy, cyanotic skin are signs of what? - ANSDecompensated/Progressive shock Obtunded/comatose, profound hypotension, bradycardia, dysrhythmias, slow shallow respirations, petechiae/purpura are signs of what? - ANSIrreversible shock Benefits of the trauma nursing process - ANSSystematic approach to the evaluation of each trauma patient. Identifies life-threatening conditions, determines priorities of care. Efficient production of ATP, which maintains cellular metabolic function, is seen with what type of metabolism? - ANSAerobic metabolism Inefficient production of ATP, byproduct is lactic acid, leads to metabolic acidosis, cellular dysfunction leads to cell death with what type of metabolism? - ANSAnaerobic metabolism The cellular process in which oxygen is used to metabolize glucose. Energy is produced in an efficient manner with minimal waste products. - ANSAerobic metabolism The cellular process in which glucose is metabolized into energy without oxygen. Energy is produced in an inefficient manner with many waste products. - ANSAnaerobic metabolism What is included in the Trauma Triad of Death? - ANSCoagulopathy Acidosis Hypothermia Pump failure, caused by blunt cardiac injury, dysrhythmias, or myocardial infarction is what type of shock? - ANSCardiogenic Shock What type of shock is caused by cardiac tamponade or tension pneumothorax? Ventricular failure is seen. - ANSObstructive Shock Reservoir depletion and hemorrhage cause which type of shock? - ANSHypovolemic Shock Vasodilation, anaphylaxis, sepsis, and spinal cord injuries cause which type of shock? - ANSDistributive Shock Options for hemorrhage - ANSPressure at site, tourniquet, hemostatic dressings, Massive Transfusion Protocol, Tranexamic Acid (clotting promoter) Treatment for cariogenic shock - ANSinotropic support, anti-dysrhythmic medications, treat myocardial infarction or other underlying cause Treatment for obstructive shock - ANSpericardiocentesis, cardiac window, needle decompression, position pregnant patient on L side Treatment for distributive shock - ANSSupport ventilations, vasopressors, pain management, apply warming methods Treatment for hypovolemic shock - ANSTourniquet, 1:1:1 blood products, massive transfusion protocol, TXA, surgical repair Subdural hematoma is caused by tearing of the ______ veins and symptoms usually present within ____ hours of the accident. - ANSBridging; 72 Epidural hematoma is caused by an arterial or venous bleed? Sx are transient LOC followed by a lucid period. - ANSArterial Hyperventilation causes cerebral blood vessels to do what? - ANSConstrict A patient fell two weeks ago, striking their head. Today, the patient presented with a persistent headache and nausea and was diagnosed with a small subdural hematoma. The patient has been in the ED for 24 hours awaiting an inpatient bed. The night shift nurse reports the patient has been anxious, restless, shaky, and vomited twice during the night. The patient states they couldn't sleep because a young child kept coming into the room. What is the most likely cause for these signs and symptoms? a. increase intracranial pressure b. alcohol withdrawal c. rhabdomyolysis d. pulmonary embolus - ANSb. alcohol withdrawal Treatment for frostbite can include which of the following interventions? a. warm the affected part over 30-60 minutes b. use gentle friction to improve circulation c. administer tissue plasminogen activator d. leave all of the blisters intact - ANSc. administer tissue plasminogen activator A patient with a spinal cord injury at C5 is being cared for in the emergency department while awaiting transport to a trauma center. Which of the following represents the highest priority for ongoing assessment and management for this patient? a. maintain adequate respiratory status. b. administer balanced resuscitation fluid c. perform serial assessments of neurologic function d. maintain core temperature - ANSa. maintain adequate respiratory status Following a bomb explosion, fragmentation injuries from the bomb or objects in the environment are examples of which phase of injury? a. primary b. secondary c. tertiary d. quaternary - ANSb. secondary Which of the following is considered a cornerstone of a high-performance trauma team? a. Individual goals b. Use of TeamSTEPPS c. Identification of a single decision maker d. Effective communication - ANSd. Effective communication The nurse is obtaining a history for a patient who presents following sexual assault. This history is completed using which of the following techniques? a. Bring the family in to the interview room. b. Use direct quotes to record information. c. Obtain information specific only to the assault. d. Provide food and drink to help create rapport. - ANSb. Use direct quotes to record information. In a patient with severe traumatic brain injury, hypocapnia causes which condition? a. Respiratory acidosis b. Metabolic acidosis c. Neurogenic shock d. Cerebral vasoconstriction - ANSd. Cerebral vasoconstriction What is the appropriate technique for palpating the pelvis for stability? a. Apply gentle pressure over the iliac crests, downward and laterally. b. Apply gentle pressure over the iliac crests, downward and medially. c. Apply firm pressure over the iliac crests, downward and laterally. d. Apply firm pressure over the iliac crests, downward and medially. - ANSb. Apply gentle pressure over the iliac crests, downward and medially. What does the J stand for at the end of the secondary survery? - ANSjust keep evaluating - vipp What does VIPP stand for? - ANSvital signs, injuries/interventions, primary survey, pain During the head-to-toe, where would you find Grey-Turner's sign? - ANSflank During the head-to-toe, where would you find Cullen's sign? - ANSumbilicus What is sometimes deferred at the end of the head-to-toe? - ANSinspecting posterior Antibiotics, consults, head CT, imaging, law enforcement, mandatory reporting, psychosocial support, social services, splinting, tetanus, and wound care are all interventions that you do AFTER and before WHAT? - ANSAFTER head-to-toe, BEFORE J (VIPP) What three items are obtained during the pertinent history assessment? - ANSMedical records, prehospital report, SAMPLE What are examples of nonpharmacologic measures? (must identify at least one during testing) - ANSDistraction, family presence, padding bony prominences, repositioning, splinting, verbal reassurance For whom is capnography highly recommended? - ANSall patients In step M of "Get Adjuncts", what else might be indicated besides cardiac monitor? - ANSEKG In Step 16 of "Exposure and Environment", you must name at least one of these interventions: - ANSblankets, room temp increase, warmed fluids, warming lights At what point PRIOR TO the head-to-toe is the patient inspected for obvious injuries? - ANSIn Step 15 of "Exposure and Environment" In Step 13 of "Disability", what is assessed if pt is altered? - ANSglucose To assess circulation, you must do these two main tasks: - ANS1. inspect AND palpate skin color, temp, moisture and 2. palpate a pulse What do you do when alterations are identified in any of the steps in the primary survery? - ANSintervene as appropriate and reassess What three assessments must be done if the patient is intubated? - ANS1. attach CO2 detector and assess for evidence of exhaled CO2; 2. observe for rise and fall of the chest w/ assisted ventilations; 3. auscultate over epigastrium for gurgling AND lungs for bilateral breath sounds Four of these must be identified to assess breathing effectiveness: - ANSBreath sounds, depth/pattern/rate, spontaneous breathing, subcutaneous emphysema, increased work of breathing, symmetrical chest rise and fall, tracheal deviation/JVD, open wounds/deformities, skin color What can be applied in step 12 of "Circulation and Control of Hemorrhage" for which credit is given in the LMNOP section? - ANScardiac monitor When should 2 IV sites be established? - ANSDuring "Circulation" assessment If the patient is intubated and you've already assessed ETT placement, what else needs to be done with the ETT? (step 10) - ANSassess ETT position by noting the number at teeth/gums AND secure ETT What should you verbalize after completing all ETT assessments? - ANSmoving patient from assisted ventilation to mechanical During which part of the primary survey would you anticipate the need for a chest tube, intubation, decompression of pneumothorax, oxygen, or BVMs? - ANS"Breathing and Ventilation" Four of these must be identified to assess patency and protection of the airway: - ANSbony deformity, loose teeth, edema, inhalation injury, sounds, tongue obstruction, burns, fluids, foreign objects, vocalization During which part of the primary survey would there be anticipation for intubation, insertion of OPA/NPA, removal of any loose teeth or foreign objects, or suctioning? - ANSAssessing patency and protection of the airway, Step 7 of "Alertness and Airway with Simultaneous Cervical Spinal Stabilization" If c-spine stabilization is necessary, what need should be stated? - ANSthe need for a second person to provide manual c-spine stabilization An adult patient who sustained a severe head trauma has been intubated and is being manually ventilated via a bag-mask device at a rate of 18 breaths/minute. The patient has received one intravenous fluid bolus of 500 mL of warmed isotonic crystalloid solution. The PaCO2 is 30 mm Hg (4.0 kPa), and the pulse oximetry is 92%. BP is 142/70 mm Hg. What is the most important intervention to manage the cerebral blood flow? A.Decrease the rate of manual ventilation. B.Initiate another fluid bolus. C.Re - ANSA.Decrease the rate of manual ventilation. An older adult presents to the emergency department with complaints of dizziness, headache, and nausea. The patient was involved in a motor vehicle collision 10 days ago. There was no loss of consciousness and a hematoma is noted to the forehead. The patient is currently on anticoagulant therapy. What is most likely the cause of their symptoms? A.Intracerebral hemorrhage B.Epidural hematoma C.Diffuse axonal injury D.Post-concussive syndrome - ANSpost-concussive syndrome A patient with a lower extremity fracture complains of severe pain and tightness in his calf, minimally relieved by pain medications. Which of the following is the priority nursing intervention? A.Elevating the leg above the level of the heart B.Repositioning the leg and applying ice C.Elevating the leg to the level of the heart D.Preparing the patient for ultrasound of the leg - ANSC.Elevating the leg to the level of the heart An adult was thrown against a concrete wall during a factory explosion and sustained a femur fracture, liver laceration, and a small subdural hematoma. These injuries most likely occurred during what level of blast trauma? A.Primary B.Secondary C.Tertiary D.Quaternary - ANSC.Tertiary An adult patient was brought to the emergency department following a motorcycle crash. On arrival, the patient is only responsive to pain, has bleeding from the nose, and multiple abrasions and contusions to the face. What is the priority intervention? A.Use a bulb syringe to suction out secretions from the mouth. B.Insert a nasopharyngeal airway to maintain an open airway. C.Use a jaw thrust to open the airway and look for signs of obstruction. D.Ask the patient to open their mouth to inspect - ANSC.Use a jaw thrust to open the airway and look for signs of obstruction. An adult pedestrian was struck on the right side by a sport utility vehicle traveling at 40 mph. The patient is awake and alert and the right leg is shortened. Following initial resuscitation with fluids, the patient remains hypotensive. What would be the priority intervention? A.Send blood for type and crossmatch B.Apply a pelvic binder C.Prepare the patient for surgery D.Insert a urinary catheter - ANSApply a pelvic binder A severely injured patient has been intubated and is being mechanically ventilated. The patient has received a balanced resuscitation including multiple blood products. Under which circumstance will it be harder for the hemoglobin to release oxygen to the tissues? A.Decreased pH B.Elevated carbon dioxide level C.Decreased body temperature D.Increased metabolic demand - ANSC.Decreased body temperature A patient is thrown against a car during a tornado and presents with obvious bilateral femur fractures. The patient is pale, alert, disoriented, and has delayed capillary refill. Which of the following interventions would be most appropriate for this patient based on the disaster triage principles? A.Initiate two large-caliber intravenous lines for isotonic crystalloid administration. B.Administer intravenous medications for pain. C.Place the patient in an observation area for care within the n - ANSInitiate two large- caliber intravenous lines for isotonic crystalloid administration. 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. The patient 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? A.Needle decompression B.Tube thoracostomy C.Dressing removal D.Surgical repair - ANSC.Dressing removal A driver involved in a high-speed motor vehicle collision arrives in the emergency department. The vehicle's air-bag failed to deploy. The patient is drowsy but arousable and complaining of chest pain with ecchymosis noted to the chest. The patient is tachycardic and hypotensive with no evidence of uncontrolled bleeding. Cardiac monitor shows premature ventricular contractions. Which of the following is the most appropriate intervention for this patient? A.Rapid fluid boluses B.Tranexamic acid - ANSC.Inotropic support A patient is diagnosed with a T12 spinal cord injury following a 20-foot fall. Which finding is consistent with spinal shock? A.Bradycardia B.Loss of reflexes C.Widened pulse pressure D.Warm skin - ANSB.Loss of reflexes A patient with a traumatic brain injury has a mean arterial pressure (MAP) of 65 mm Hg (8.66 kPa) and an intracranial pressure (ICP) of 22 mm Hg (2.93 kPa). Which finding is most likely an indication of the body's response to these findings? A.Reflex hypotension B.Increased respiratory effort C.Reflex tachycardia D.Widening pulse pressure - ANSD.Widening pulse pressure An unconscious patient arrives following a motor vehicle collision. The patient is on a backboard with a cervical collar in place and one intravenous line running. Respirations are shallow and there is active brisk bleeding from a large leg wound. What is the priority intervention for this patient? A.Check for a patent airway B.Control the bleeding C.Start a second intravenous line D.Ventilate with a bag-mask device - ANSB.Control the bleeding An obese trauma patient requires intubation. Assuming there are no contraindications, which position will provide the best visualization for insertion of the endotracheal tube? A.Reverse Trendelenburg B.Lying on side C.Ramped D.Supine - ANSC.Ramped Your patient is a pedestrian struck by a car and thrown 35 feet. They were unconscious at the scene but became responsive with initial and subsequent Glasgow Coma Scale (GCS) scores of 13 (E-3, V-4, M-6). The patient has bilateral subdural hematomas and is awaiting transfer to the ICU. Your next assessment reveals a GCS of 9 (E-2, V-2, M- 5). What is the priority nursing intervention? A.Hold all pain medications B.Notify the provider of the change C.Repeat the GCS in 30 minutes D.Place the patie - ANSB.Notify the provider of the change A patient arrives following prolonged exposure of their left hand to the cold. The patient is awake and alert and complains of a tingling sensation to the fingers. Assessment reveals swelling and bright red skin to the left hand and a 1-inch round clear blister to the dorsum of that hand. Which of the following nursing interventions is most appropriate for this patient? A.Massage the injured areas to promote circulation B.Drain and debride the blister on the hand C.Immerse in water between 37.5 - ANSD.Gently rewarm over 15 to 30 minutes A nurse verbalizes guilt and remorse after caring for multiple severely injured patients during a staffing crisis. The nurse expresses anger stating that the patients did not receive quality care and begins exhibiting aggression toward colleagues. This is most consistent with which condition? A.Compassion fatigue B.Vicarious trauma C.Secondary traumatic stress D.Moral injury - ANSD.Moral injury What is the rationale for obtaining a serum lactate level during the initial assessment of a trauma patient? A.Open the airway with the head-tilt/chin-lift maneuver B.Auscultate bilateral breath sounds C.Assist respirations using a bag-mask device D.Insert an oropharyngeal airway if there is no gag reflex - ANSD.Insert an oropharyngeal airway if there is no gag reflex A trauma patient is being held in the emergency department because there are no available inpatient beds. The patient sustained a femur fracture and required multiple blood products. The patient now has blood oozing from abrasions, IV sites, the nose, and gums. What condition is most consistent with these findings? A.Rhabdomyolysis B.Fat embolism C.Disseminated intravascular coagulopathy D.Multiple organ dysfunctions syndrome - ANSC.Disseminated intravascular coagulopathy A patient is brought to the emergency department following a snowmobile crash with prolonged exposure time prior to transport. The patient is confused. Vital signs are BP 96/54 mm Hg, HR 114 beats/minute, RR 24 breaths/minute, T 34.6oC (94.2oF) and an SpO2 of 90% on oxygen at 15L per non-rebreather mask. Other findings include ETCO2 24, serum lactate of 6 mmol/L, and a pH of 6.8. Based on these findings, what is the most appropriate intervention? A.Initiate warming measures B.Titrate oxygen to - ANSA.Initiate warming measures Which of the following is a late sign of increased intracranial pressure? A.Restlessness B.Vomiting C.Decreased respiratory effort D.Narrowing pulse pressure - ANSC.Decreased respiratory effort Based on fall mechanism, which patient warrants prehospital transfer to a trauma center? A.A 35-year-old lands on a wooden porch from an 8-foot ladder B.A 2-year-old lands on grass from a second-story balcony C.A 14-year-old forcefully pushed onto cement from standing D.A 50-year-old lands on a carpeted floor after tripping - ANSB.A 2-year-old lands on grass from a second-story balcony The trauma nurse is caring for an unrestrained driver who struck their head on the windshield following a high-speed MVC. The patient has been diagnosed with an anterior spinal cord injury at the level of C6. Which assessment finding would be most concerning? A.Distension of the bladder B.Incontinence of stool C.Increasing work of breathing D.Inability to move the legs - ANSC.Increasing work of breathing While caring for a child who has been injured, what nursing intervention is consistent with a family-center approach? A.Identifying a single family member to speak with B.Having the family make all the care decisions C.Allowing family to participate in the care of the patient D.Limiting dissemination of complex information - ANSC.Allowing family to participate in the care of the patient A patient is brought to the emergency department with chest pain and shortness of breath following a high-speed motor vehicle collision in which they were the unrestrained driver. There is crepitus to the left chest with clear and equal breath sounds. The vital signs are BP 80/40 mmHg, HR 140 beats/minute, and RR 40 breaths/minute. Cardiac monitor shows sinus tachycardia with premature ventricular contractions. These findings are most consistent with which type of shock? A.Cardiogenic B.Neuroge - ANSA.Cardiogenic A trauma patient who is 30-weeks pregnant arrives at the emergency department following a motor vehicle collision. Which normal physiologic change should be considered when assessing ventilatory status? A.Increased functional reserve capacity B.Increased oxygen consumption C.Decreased minute ventilation D.Slower desaturation rates with apnea - ANSB.Increased oxygen consumption A patient who sustained severe injuries was brought to the emergency department following a high-speed motor vehicle collision. Interventions for hypovolemic shock have been initiated. What component of the trauma triad of death is most likely to have begun at the time of injury? A.Acidosis B.Hypothermia C.Hypocalcemia D.Coagulopathy - ANSD.Coagulopathy An adult patient involved in a motor vehicle collision is brought to the emergency department of a rural critical access facility. They complain of neck pain, shortness of breath, and diffuse abdominal pain. The Glasgow Coma Score is 15. Vital signs are: BP 98/71 mm Hg, HR 125 beats/minute, RR 26 breaths/minute, and SpO2 94% on high- flow oxygen via non-rebreather mask. Which of the following is the priority intervention for this patient? A.Expedite transport to the CT scanner B.Prepare the pati - ANSC.Expedite transfer to the closest trauma center A patient who weighs 120 kg is brought to the emergency department after sustaining partial thickness burns to both upper extremities and chest with a total body surface area burned of 27%. How much intravenous fluid should be administered in the first 8 hours? A.1620 mL B.2160 mL C.3240 mL D.6480 mL - ANSC.3240 mL You are caring for a patient who was thrown from a bike and was not wearing a helmet. While performing the head-to-toe assessment, you note clear drainage from the right ear. Which of the following is the most appropriate next step? A. Clean the ear with a cotton-tipped applicator. B. Pack the ear with gauze. C. Notify the physician D. Document and continue the exam. - ANSC. Notify the physician A patient is brought to the emergency department of a rural hospital following a high- speed motor vehicle collision. When significant abdominal and pelvic injuries are noted in the primary survey, what is the priority intervention? A. Initiate transfer to a trauma center B. Attempt family notification C. Obtain additional imaging studies D. Place an indwelling urinary catheter - ANSA. Initiate transfer to a trauma center An adult who fell from a second story roof is brought to the emergency department by private vehicle. The patient is confused with unlabored respirations and has strong, palpable radial pulses. There is an open wound in proximity to an obvious deformity of the left lower extremity. What is the priority intervention? A. Initiate cervical spine stabilization B. Apply a splint to the lower extremity C. Put the patient on portable oxygen. D. Log roll the patient onto a spine board - ANSA. Initiate cervical spine stabilization and complaining of chest pain with ecchymosis noted to the chest. The patient is tachycardic and hypotensive with no evidence of uncontrolled bleeding. Cardiac monitor shows premature ventricular contractions. Which of the following is the most appropriate intervention for this patient? A.Rapid fluid boluses B.Tranexamic acid administration C.Inotropic support D.Epinephrine administration - ANS A trauma patient who is 30-weeks pregnant arrives at the emergency department following a motor vehicle collision. Which normal physiologic change should be considered when assessing ventilatory status? A.Increased functional reserve capacity B.Increased oxygen consumption C.Decreased minute ventilation D.Slower desaturation rates with apnea - ANS A trauma patient is being resuscitated in the emergency department when the radiology staff notifies the charge nurse that the computed tomography (CT) scanner will be out of service for several hours. The team gathers to plan accordingly. Which of the following terms best describes this trauma team's communication? A.Brief B.Closed-loop C.Debrief D.Huddle - ANS An adult pedestrian was struck on the right side by a sport utility vehicle traveling at 40 mph. The patient is awake and alert and the right leg is shortened. Following initial resuscitation with fluids, the patient remains hypotensive. What would be the priority intervention? A.Send blood for type and crossmatch B.Apply a pelvic binder C.Prepare the patient for surgery D.Insert a urinary catheter - ANS A patient with a traumatic brain injury has a mean arterial pressure (MAP) of 65 mm Hg (8.66 kPa) and an intracranial pressure (ICP) of 22 mm Hg (2.93 kPa). Which finding is most likely an indication of the body's response to these findings? A.Increased respiratory effort B.Reflex tachycardia C.Widening pulse pressure D.Reflex hypotension - ANS While caring for a child who has been injured, what nursing intervention is consistent with a family-center approach? A.Identifying a single family member to speak with B.Having the family make all the care decisions C.Allowing family to participate in the care of the patient D.Limiting dissemination of complex information - ANS Which of the following is true about use of the focused assessment sonography for trauma exam for a patient with abdominal trauma? A.It has a higher sensitivity than diagnostic peritoneal lavage for fluid detection B.It can be used in hypotensive patients too unstable for computed tomography scan C.It can detect as little as 30 mL of fluid in the abdominal cavity D.It has high sensitivity in pediatric patients for identifying fluid in the peritoneum - ANS What technique is most effective when obtaining a history from a patient who has experienced a sexual assault? A.Sitting next to the patient. B.Ensuring the patient answers all the questions. C.Asking for information only related to the assault. D.Using direct quotes to record information. - ANS A trauma patient is being held in the emergency department because there are no available inpatient beds. The patient sustained a femur fracture and required multiple blood products. The patient now has blood oozing from abrasions, IV sites, the nose, and gums. What condition is most consistent with these findings? A.Rhabdomyolysis B.Fat embolism C.Disseminated intravascular coagulopathy D.Multiple organ dysfunctions syndrome - ANS An unconscious patient arrives following a motor vehicle collision. The patient is on a backboard with a cervical collar in place and one intravenous line running. Respirations are shallow and there is active brisk bleeding from a large leg wound. What is the priority intervention for this patient? A.Check for a patent airway B.Control the bleeding C.Start a second intravenous line D.Ventilate with a bag-mask device - ANS A restrained driver involved in a motor vehicle collision is brought to the emergency department with abdominal, pelvic, and bilateral lower extremity pain. Vital signs are BP 114/78 mm Hg, HR 98 beats/minute, RR 22 breaths/minute. A FAST exam is negative for fluid in the abdominal and peritoneal cavities. Which of the following should the nurse anticipate? A.Diagnostic peritoneal lavage B.Angiography C.Operative management D.Serial abdominal assessments - ANS A patient is brought to the emergency department following a snowmobile crash with prolonged exposure time prior to transport. The patient is confused. Vital signs are BP 96/54 mm Hg, HR 114 beats/minute, RR 24 breaths/minute, T 34.6oC (94.2oF) and an SpO2 of 90% on oxygen at 15L per non-rebreather mask. Other findings include ETCO2 24, serum lactate of 6 mmol/L, and a pH of 6.8. Based on these findings, what is the most appropriate intervention? A.Initiate warming measures B.Titrate oxygen to 6 L per nasal cannula C.Bolus with 500 mL isotonic crystalloids D.Vigorously massage the extremities - ANS A patient presents with chest pain and shortness of breath following a motor vehicle collision. An electrocardiogram shows sinus tachycardia and ischemic changes with an elevated troponin. The nurse should be highly suspicious for which injury? A.Cardiac tamponade B.Blunt cardiac injury C.Aortic disruption D.Pulmonary contusion - ANS What intravascular solution is most commonly used for patients who have sustained burns? A.Lactated Ringer's B.Normal saline C.D5 / normal saline D.Hypertonic saline - ANS A patient has been diagnosed with an incomplete spinal cord injury at L1. Which finding would indicate sacral sparing? A.Involuntary flexion of the great toe B.Priapism C.Voluntary anal sphincter tone An adult who fell from a second story roof is brought to the emergency department by private vehicle - ANSABC A trauma patient is restless and repeatedly asking "where am I?" Vitals upon arrival were 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? - ANScompensated A 35-year-old male 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? - ANSglobe rupture An adult patient with a restraint passenger involved in a high-speed motor vehicle collision. The passenger - ANS What intravascular solution is most commonly use for patients who have sustained burns? - ANSLactated Ringers (LR) You are speaking with the family of a critically injured patient. The spouses, crying loudly and the - ANS Which of the following is true about use of the focused assessment sonography for trauma exam for a - ANS A patient with a chest tube is being transported to the intensive care unit and fluctuation is noted - ANS A trauma patient is being held in the emergency department, because there are no available inpatient beds - ANS A patient has uncontrolled bleeding from a wound to his right upper extremity. What is a priority intervention? - ANS A patient has received multiple transfusions of banks blood in the past two hours. the patient has - ANS Three adults present at different times during a one hour. With a high fever, fatigue, and headache - ANS A trauma patient who is 30 weeks pregnant arrives at the emergency department following a motor vehicle crash - ANS Following a gunshot wound prehospital providers report diminished breath sounds bilaterally. Upon - ANS A patient with a traumatic brain injury has a mean arterial pressure of 65 mm Hg and - ANS An adult patient involved in assault presents with shortness of breath, BP 88/50 MMHG heart rate - ANS Which blood pressure finding is associated with early or compensated hypovolemic shock? - ANS A patient who jumped out of a second floor window, landing on their feet is diagnosed with a lumbar spinal - ANS During the primary survey of an unconscious, patient with multisystem trauma, the nurse notes snoring, respirations - ANS A patient with a complete spinal cord injury, who is a neurogenic shock will demonstrate hypotension - ANS When can an accurate determination of total body surface area burned be made an order to make - ANS A patient is thrown against a car during a tornado in presents with obvious bilateral femur fractures - ANS A restrained driver involved in a motor vehicle collision is brought to the emergency department with - ANS A patient is diagnosed with a T 12 spinal cord injury, following a 12 foot for which finding is consistent - ANS A patient arrives with a large open chest wound after being assaulted with a machete. Prehospital professionals - ANS What assessment finding is consistent with impending herniation syndrome? - ANS A nurse, verbalizes, guilt and remorse after caring for multiple severely injured patience during a - ANS You are caring for a patient who has thrown from a bike and was not wearing a helmet. While performing. - ANS A patient who weighs 120 kg is brought to the emergency department after sustaining partial thickness burns - ANS A teenage patient presents to the emergency department with left arm pain after a ground level fall - ANS Which of the following is a late sign of increased intracranial pressure? - ANS A patient is brought to the emergency department of a rural hospital following a high- speed, motor vehicle crash - ANS And unconscious patient arrives following a motor vehicle collision. The patient is on the backboard with. - ANS Your patient is a pedestrian struck by a car and third and 35 feet. They were unconscious at the scene. - ANS What is the most important consideration during the initial assessment when caring for an older adult? - ANS What position optimizes ventilation in the obese patient with a lumbar fracture? - ANS 836 year old. Patient has a deformity of the left wrist after a fall. The patient is reluctant to move. - ANS What is the rationale for obtaining a serum lactate level during the initial assessment of a trauma patient - ANS An older adult presents to the emergency department with complaints of dizziness, headache, and nausea - ANS A patient with a lower extremity fracture, complains of severe pain and tightness in his calf, minimal - ANS Face on full mechanism, which patient warrants prehospital transfer to a trauma center - ANS Which of the following is true regarding cavitation? - ANS A patient has been diagnosed with an incomplete spinal cord injury at L1. Which finding would indicate. - ANS Following a motor vehicle collision, a patient presents with decreased level of consciousness and respiratory - ANS A patient arrives at the emergency department following a motor vehicle collision. Prehospital personnel. - ANS You are caring for a patient who was involved in a motor vehicle crash and is 32 weeks pregnant. Find. - ANS An adult patient is brought to the emergency department, following a vehicle rollover with prolonged - ANS After identifying potential interventions/diagnostics and completing your assessments and interventions, you should ask yourself what? - ANS"What findings will you continue to reevaluate while the patient is in your care?" "Just keep re-evaluating" Just Keep Reevaluating. 45-48 - ANS45. Reevaluate vital signs 46. Reevaluate all identified injuries and effectiveness of interventions 47. Reevaluate primary survey 48. Reevaluate pain What do you ask yourself after re-evaluations are done? 49-50 - ANS49. "What is the definitive care for this patient?" 50. Consider need for transfer to a trauma center or admission After all of the assessments, interventions, reassessments, etc. are done, what is the last thing to ask? - ANS"Is there anything you would like to add at this time?" When considering GU and how to monitor urinary output: - ANS- Assess for contraindications for an indwelling urinary catheter - External catheter - Weighing diapers (pediatrics and adults) How do you first assess for pelvic instability? Then what do you do? - ANSApply gentle pressure over iliac crests downward and medially. If iliac crests are stable, then apply gentle pressure on the symphysis pubis. T/F: It is appropriate to consider transfer to a higher level of care before or during the A- E. - ANSTrue. Consider this throughout. What is a systematic process to guide your care of trauma patients? - ANStrauma nursing process What does it mean to have double-starred criteria? - ANSIt means that this criteria MUST be done in order. For double-starred criteria, ___ and ___ must be completed prior to moving to the next step. - ANSassessments, interventions Double-starred criteria include letters ___-___. - ANSA-E What does it mean to have single-starred criteria? - ANSThis means the criteria needs to be done, but the sequence is not critical. **A stands for ___ and ___. - ANSalertness, airway **B stands for ___ and ___. - ANSbreathing, ventilation **C stands for ___. - ANScirculation **D stands for ___. - ANSdisability **E stands for ___. - ANSexposure What are the 4 potential single-starred criteria? - ANS- reassessment of primary survey interventions - blood glucose if alterations in mental status noted in disability assessment - pain assessment using appropriate pain scale - inspection of posterior surfaces (unless CI) Why might inspection of posterior surfaces be contraindicated? - ANSMay be contraindicated by suspected spine or pelvic injury You must assess pain using an ___________. - ANSappropriate pain scale What are the double-starred criteria? (hint: A-E) - ANS**Alertness and Airway **Breathing and Ventilation **Circulation **Disability **Exposure T/F: Preparation and triage in TNP includes the activation of the trauma team, role assignment, preparation of the trauma room, and donning PPE. - ANSTrue What might you ask yourself during preparation and triage? - ANS"Is there any specific equipment that you would prepare?" Trauma room preparations might include: - ANS- Bariatric equipment - Difficult airway or IV equipment - Fluid warmer - Pediatric equipment While donning PPE, you should consider 2 things: - ANS1. potential safety threats to the team 2. need for decontamination The general impression in TNP is to... - ANSAssess for obvious uncontrolled external hemorrhage or unresponsiveness/apnea and the need to reprioritize to C-ABC. What might need to be reprioritized during the general impression? Why? - ANSYou may need to switch from ABCs to C-ABCs in the case of uncontrolled external hemorrhage. During the general impression in TNP, when alterations are identified, you must do what? Then what? - ANSIntervene as appropriate and continuously reassess for efficacy What interventions are potentially included in the general impression? - ANS- pulse - control of external hemorrhage - initiation of chest compressions - initiation of IV resuscitation Why would you initiate IV resuscitation? - ANSfor signs of significant blood loss with signs of very poor perfusion T/F: During the general impression, you can perform the assessment and interventions simultaneously when multiple team members are present. - ANSTrue. T/F: During the general impression, assessments and interventions identify life- threatening conditions, and you should prioritize the life-saving interventions. Order of step completion is not important. - ANSFalse. Order of step completion is of critical importance. What is the first double-starred assessment? What step is it? - ANSAlertness and AVPU are the first double-starred assessments. It is step 5**. What should you ask yourself when assessing for alertness, avpu? - ANSIs the patient Alert, do they require a Verbal or Painful stimulus to respond, or are they Unresponsive? T/F: If the patient was deemed unresponsive in step 4, you do not need to assess level of alertness, avpu. - ANSTrue General impression is step 4, and if you already know the patient is unresponsive, they won't be alert or responsive. What 2 things must you do when opening the airway if c-spine injury is suspected? - ANS1. You need to have a second person provide manual cervical spinal stabilization 2. You must demonstrate manual opening of the airway using the jaw-thrust maneuver When assessing for alertness and airway, you must simultaneously ___________. - ANScontinue cervical spinal stabilization T/F: Even if the patient is alert and can cooperate, you must demonstrate manual opening of the airway using the jaw-thrust maneuver. - ANSFalse. When the patient is alert and can cooperate, it is acceptable to ask the patient to open their mouth to assess the airway. What are some interventions that may be appropriate when alterations in neurological status are noted with GCS? - ANS- Anticipate the need for a head CT - Anticipate the need for drug-assisted intubation - Assess bedside glucose (*with altered mental status) You should determine neurological status using GCS ___ (before / after) sedation and intubation. - ANSbefore T/F: The GCS is documented as non-testable if there is a factor, such as sedation or paralytics, interfering with communication. - ANSTrue. This is why you should determine neurological status prior to administering medication for intubation if possible. When you remove all clothing, you are also doing what? - ANSyou're also inspecting for obvious abnormalities or injuries T/F: When newly identified life-threatening alterations are identified, intervene as appropriate and reassess. - ANSTrue. Always intervene and reassess. T/F: Delay removal of transport device when possible. - ANSFalse. If a transport device is in place, it may be removed as soon as possible. If there are no contraindications, the patient may be turned to quickly assess the ___. This is deferred until after the head-to-toe and imaging if needed to evaluate spinal and pelvic stability. - ANSposterior You must provide warmth by identifying at least one of the following: - ANS- Blankets - Increase room temperature - Warmed fluids - Warming lights L in LMNOP - ANSLabs May include but not limited to the following: Blood gases Blood cross/type and screen Coagulation studies Complete blood count Lactate Metabolic panel Pregnancy Toxicology screen M in LMNOP - ANSmonitor cardiac status and consider EKG - also set BP to recycle as indicated O in LMNOP - ANSoxygen and EtCO2 P in LMNOP - ANSassess pain If alterations in oxygenation or EtCO2 are noted, interventions may include but are not limited to the following: - ANS- Increase or decrease rate of assisted ventilation - Wean oxygen (consider parameters other than oximetry due to hypothermia, vasoconstriction, and skin color's impact on pulse oximetry measurements) When is capnography highly recommended? When is capnography vital? - ANSrecommended for all patients, vital for sedated or ventilated patients You must identify at least one of the following non-pharmacological comfort measures: - ANS- Distraction - Family presence - Places padding over bony prominences - Repositioning - Splinting - Verbal reassurance What should be considered when applying ice to patients for comfort? - ANSApplying ice to swollen areas may be appropriate but consider hypothermia risk for major trauma and very small pediatric patients. What should be considered when providing warmth? - ANSWarmth may be appropriate, but consider burn risk. Identify at least one of the following when obtaining pertinent history: - ANS- Medical records/documents - Prehospital report - SAMPLE Why is alertness included in the airway assessment? - ANSIncluding this helps evaluate the patient's ability to protect their own airway What pneumonic is used to assess a patient level of alertness? - ANSA: Alert V: Responds to verbal stimuli P: Responds to pain U: Unresponsive Why is AVPU beneficial to use at the beginning of the initial patient assessment? - ANSWill help determine appropriate airway intervention In a patient who is unable to open their mouth or unresponsive, how do we assess the airway? - ANSJaw- thrust maneuver is performed to open airway and mouth to assess for obstruction What inspecting the airway, what are we inspecting for? - ANSVocalization Tongue Obstruction Loose or missing teeth Foreign objects Fluids (blood, vomit, secretions) Edema Burns/ evidence of inhalation injury If an airway is patent, what is the goal? - ANSFocusing efforts at maintaining and supporting a patent airway (Pt may be allowed to assume position that facilitates better air exchange so long as no CSI is suspected) Can an oropharyngeal airway be used in someone with a gag reflex? - ANSNo How do you assess breathing? - ANSExpose the patient's chest and inspect for the following: Spontaneous breathing Symmetrical chest rise and fall Depth, pattern and rate of resps Work of breathing (accessory muscles, pursed lip, diaphragmatic breathing) Skin colour Contusions, abrasions, deformities Open pneumothorax JVD Signs of inhalation injuries Sign of inhalation injuries - ANSSinged nasal hairs Carbonaceous sputum Hoarse voice How to assess for proper placement of a definitive airway (3 steps) - ANS1. Attach CO2 detector (assess for presence of CO2 after 5-6 breaths) 2. Adequate rise/fall of chest with assisted ventilation 3. Auscultate for gurgling over epigastrium and presence of bilateral breath sounds. Wha is a result of inadequate oxygenation? - ANSHypoxemia Resulting in anaerobic metabolism and acidosis ETCO2 level indicating effective ventilation - ANS35-45 mm (Greater than 50 signifies depressed ventilation What is a definitive airway? - ANSTube securely placed in the trachea with cuff inflated.