TCRN Exam Questions and Answers (Latest Update 2024), Exams of Nursing

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Referred left shoulder pain, usually indicates a splenic injury - Correct Answer ✅ Kehr's sign Base deficit more than -6 indicates the need for agressive resuscitation and determination of the etiology - Correct Answer ✅ Base deficit Most important tool providing useful information in the early minutes. Can identify major sources of blood loss from injuries in the chest or elevated diaphragm with displacement of abdominal organs - Correct Answer ✅ CXR Should be suspected if after chest tube placement a significant air leak is present - Correct Answer ✅ Tracheobronchial injury Alternative to FAST scan to detect abd bleeding. A urinary catheter and gastric tube should be in place prior to procedure. - Correct Answer ✅ Diagnostic Peritoneal Lavage

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Focused Assessment with Sonography in Trauma. Used to detect free fluid in peritoneum or hemoperitoneum. Free fluid appears "black" on the screen. Has replaced DPL when available. - Correct Answer ✅ FAST Hemodynamically unstable trauma patient with a positive fast are taken directly to the OR for laparotomy - Correct Answer ✅ Positive FAST scan Not useful to detect injuries to the diaphragm, intestine and pancreas. In patients with obesity, ascites and/or subQ emphysema the accuracy is reduced. - Correct Answer ✅ Ultrasound abd exam Hemodynamically stable patients may be taken to CT - Correct Answer ✅ CT scan Embolization is useful in treating patient with unstable pelvic fractures, liver and splenic hemorrhage. Use of hybrid OR suites to allow for surgical and interventional radiology methods of treatment simultaneously. - Correct Answer ✅ Angiography

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Can be used to detect or exclude finding so f hemoperitoneum, organ injury, intestinal spillage or peritoneal penetration. Most useful in evaluating possible diaphragmatic injuries, espectially in penetrating thoracoabdominal injuries on the left site - Correct Answer ✅ Diagnostic laparoscopy Usually resultant of penetrating throacoabdominal injuries on the left side, including 11-12 rib fractures on the left. - Correct Answer ✅ Diaphragmatic injuries Result from shearing forces in MVC or direct blows that crush intestine between force and the vertebrae. Most commonly intra-abd injury in penetrating trauma. Occurs often with spinal injury. Pancreatic/solid organ injury are predictive of increased risk for hollow viscus injury. Signs of peritonitis develop. Any blow to the abd/penetrating injury to the lower chest/abd should increase suspicion of injury - Correct Answer ✅ Small intestine injuries

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Control bleeding prior to exploration. Debridement and closure and ligation of bleeders. Resection for multiple defects. Observe for wound infection/abscess development - Correct Answer ✅ Treatment of small intestine injury Penetrating trauma most frequent cause. Usually conconcurrent mult-organ injuries. Usually found intraoperatively, commonly missed during exlap. Blunt force injury cause by vetebral compression. - Correct Answer ✅ Cause of duodenum injuries Identification with CT scan. Commonly patients have midepigastric or back pain with evolving peritoneal signs 6- 24 hrs after injury. Primary closure in OR, closed drainage system. Goals are to control hemorrhage, debride devitalized tissue and provide drainage. Non operative management requires close observation for expanding or ruptured hematomas causing bleeding or peritoneal contamination. - Correct Answer ✅ Duodenal injury treatment Jejunum lies in umbilical region, ileum lies in the hypogastric/pelvice regions. Lap belt can cause bowel to be

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crushed between the vertebrae and a solid object. Incorrect wearing of seatbelt increases chance for injury - Correct Answer ✅ Jejunum and ileum injuries Rare, more common in children. Penetrating trauma most common cause. May find free air on cxr/fua. Pain to epigastric/abd area, tenderness, signs of peritonitis. Bloody output from gastric tube. Surgical intervention, is gastric content leakage, copious peritoneal irrigation and delayed primary closure - Correct Answer ✅ Stomach injury Rectal injuries may be associated with severe pelvic fracture. Lethal due to sepsis related to fecal contamination. Most are due to penetrating trauma. Transverse colon most often injured. Most injuries are contusions. Laparotomy with primary repair and colostomy is performed when perforation to the colon or rectum is suspected. Abscesses can be percutaneously drained. - Correct Answer ✅ Large intestine Commonly injured due to size and location. Cause of injury is blunt and penetrating trauma. MVC most common cause. Greatest mortality risk is hemorrhage.

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High velocity GSW cause more widespread damage that creates massive hemorrhage. Suspect liver injury in any patient with blunt injury to right side. FAST scan to rule out free fluid. CT scan in hemodynamically stable patient. Graded I to IV. - Correct Answer ✅ Liver injuries Nonoperative in select patient. OR for complex lacerations/arterial blush. Angioembolization for patients with contrast pooling or arterial blush. Pack and stabilize bleeding and return to OR 24-36 hours later for removal of packing and definitive management of liver/possible closure. Aggressive intraoperative resuscitation to prevent hypothermia, coagulopathy and hemodynamic stability. Damage control surgery. - Correct Answer ✅ Treatment of liver injuries In patients with liver injury RUQ pain and jaundice may present days and weeks post injury so follow up care is important - Correct Answer ✅ Hemobilia Most commonly injured intra-abd organ. 25% of all blunt visceral injuries. LUQ trauma, lower rib fractures to left. Kehr's sign is caused by blood irritation to the phrenic nerve

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that causes referred pain to the left shoulder. CT scan is the imagining of choice for stable patients. - Correct Answer ✅ Splenic injuries left hemidiaphragm elevation, left lower lobe atelectasis and pleural effusion not commonly present and not a reliable sign

• Correct Answer ✅ Acute splenic rupture triad Nonoperative management, splenectomy/partial splenectomy, possible damage control. More focused on salvage of spleen. If patient has a splenectomy patient must receve vaccinations prior to discharge for H influenza/meningococcal/pneumococcal vaccine - Correct Answer ✅ Treatment of splenic injury Rare, more common in children. 1-5 years after surgery. Flu like symptoms, shock from sepsis and DIC followed by death. Preventative measures include vaccinations and education. - Correct Answer ✅ Overwhelming Postsplenectomy Sepsis uncommon injury. If ductal tears, digestive enzymes invade. Major therapeutic challenge for clinical team. Most are

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associated with intra-abdominal injury and are found intraoperatively. GSW/Stab wounds are frequently the cause.

• Correct Answer ✅ Pancreas Associated with blunt trauma involving pelvic fractures - Correct Answer ✅ Retroperitoneal injury Usually occur with pelvic, thoracic or visceral injury. Retroperitoneal hematoma in conjunction with pelvic or spine trauma can contain up to 4 L of blood. - Correct Answer ✅ Abdominal vascular injury failure to suspect intra-abdominal injury from mechanism of injury, failure to fully evaluate complaints of abdominal pain following blunt abdominal injury, failure to perform timely operative intervention, failure to recognize hemodynamic compromise and delay surgery for further diagnostic tests - Correct Answer ✅ Pitfalls of abdominal trauma < 750 ml/15% of blood volume, HR < 100, normal B/P, normal PP, RR 14-20, CNS slightly anxious - Correct Answer ✅ Blood loss hypovolemia: class I

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750-1500/15-30%, >100, normal BP, decreased PP, RR 20-30, Mildly anxious - Correct Answer ✅ Blood loss hypovolemia: class II 1500-2000/30-40%, HR >129, decreased b/p, decreased PP, RR 30-40, anxious/confused - Correct Answer ✅ Blood loss hypovolemia: class III

2000/>40%, HR > 140, decreased b/p, PP decreased, RR 35, confused and lethargic - Correct Answer ✅ Blood loss hypovolemia: class IV Common areas for compartment syndrome include: lower leg, forearm, foot, hand, gluteal region and thigh - Correct Answer ✅ Compartment syndrome Adult and Chemical burns > 20% TBSA resuscitate at 2 ml LR x kg x TBSA in the first 24 hrs. - Correct Answer ✅ Burn formula

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4 ml LR x kg x % TBSA in the first 24 hours - Correct Answer ✅ High voltage electrical injuries 3 ml LR x kg x % TBSA in the first 24 hours - Correct Answer ✅ Peds Burn formula (14 and under and < 40 kgs) Do not wait to intubate, swelling will increase then increase the difficulty of placing an ETT. Stridor or horseness is a late sign. - Correct Answer ✅ Inhalation injury Pain out of proportion for the injury, weak or absent distal pulses, delayed cap refil, firmness on palpation of muscle/soft tissue in surrounding area, distal skin cool to touch, distal skin pale or cyanotic, decrase in patient sensation - Correct Answer ✅ Compartment syndrome signs and symptoms children can be hemodynamically stable up to a 40% blood loss but only have a blood volume of 7-8% of their body weight - Correct Answer ✅ Hypovolemia in childresn

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chaning mentation, tachycardia, >120 HR greatest concern, cool, clammy skin, prolonged cap refill, narrowed pulse pressure (normal 40-50), decrased urine output, hypotension

• Correct Answer ✅ Hypovolemic shock Systolic blood pressure does not fall until 30% blood loss in adults - Correct Answer ✅ Hypotension in shock Systemic Inflammatory Response Syndrome. Severe physiologic reaction to injury characterized by systemic release of inflammatory cytokines and chemokines. Two or more of the following: temp > 38 or < 36, HR > 90, RR > 20 or PaCO < 32, WBC >12 or <4 or > 10% bands - Correct Answer ✅ SIRS After SIRS becomes stage 3 and severe hypotension refractory to fluid and ionotropic support ischemic insult progresses. Dysfunction of at least two organ systems from inflammatory insult, trauma or sepsis. - Correct Answer ✅ MODS

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hypoxia, hypotension, hypocapnea or hypercapnea - Correct Answer ✅ Causes of secondary brain injury Leads to cerebral edema, mass effect, ischemia, cellular death - Correct Answer ✅ Secondary brain injury Intubate with RSI, maintain O2 sat > 90%, optimally 98%, ETCO2 monitoring to keep around 35 - provides information about adequacy of circulatory flow, hyperventilation causes vasoconstriction and reduces PaCO2 and causes ischemia, PaCo2 < 30 - Correct Answer ✅ Optimizing oxygenation, ventilation and hemodynamics Pressure volume relationships within the intracranial cavity, the craium is a non-expandable vault, increasing iCP is a warning that contents under pressure will try to relieve pressure by finding an exit in the area of least resistant - brain herniation - Correct Answer ✅ Monroe-Kellie doctrine 0-15, > 20 requires intervention - Correct Answer ✅ Normal ICP

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ethmoid, parietal, sphenoid, temporal, occipital - Correct Answer ✅ 8 Cranium bones Outermost layer-firmly adhered to the inner skull with fixed attachments of the cranial sutures - Correct Answer ✅ Dura Loosely adhered to the pia mater, which makes the potential arachnoid space - Correct Answer ✅ Arachnoid closely associated with grey matter of the brain, is the innermost layer - Correct Answer ✅ Pia Between the pia and the arachnoid in the subarachnoid space, cushions and protects the brain and spinal cord - Correct Answer ✅ CSF circulates Key cause of epidural bleeds - Correct Answer ✅ Middle meningeal artery

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right and left hemispheres of the brain - Correct Answer ✅ cerebrum approx 500 ml of CSF is produced in the choroid plexus of the lateral ventricles each day - Correct Answer ✅ ventricular system brainstem is the origin for the CNIII - CNX and CNXII - Correct Answer ✅ third cranial nerve Eye opening to voice, confused verbal response, withdraws to pain - Correct Answer ✅ GCS 10 intubate, accepted definition of coma - categorized as severe brain injury - Correct Answer ✅ GCS < 8 moderate brain injury - Correct Answer ✅ GCS 9- minor brain injury - Correct Answer ✅ GCS >

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cerebral perfusion pressure, maintain 60-70 mmHg - Correct Answer ✅ CPP Solitary and multiple episodes of hypotension have been shown to increase the morbidity and mortality associated with brain injury - Correct Answer ✅ Avoid hypotension in ICH hypertension, bradycardia and irregular respirations - ominous signs of herniation and require immediate attention and possible surgical intervention - Correct Answer ✅ Cushings Triad Placed in all salvageable head injury patients with GCS < 8 after resuscitation with an abnormal CT scan, GCS < 8 after resuscitation with a normal CT scan and at least two of the following findings: over 40 yo, systolic <90, bi or unilateral posturing - Correct Answer ✅ ICP monitoring assessed through the use of devices such as the brain tissue oxygen monitoring catheter to monitor cerebral perfusion,

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oxygenation and oxygen carrying capacity - Correct Answer ✅ CPP/brain tissue oxygenation capillaries within the brain tissue are damaged and cause hemorrhage infarction or necrosis - Correct Answer ✅ Cerebral contusion deeper in the brain tissue, may be single or multiples, can create mass effect, increased ICP, neurologic deterioration, headache, incrased ICP, pupil changes, abn posturing, hemiparesis, hemipalegia - Correct Answer ✅ Intracerebral Venous bleeding, acute < 72 hours old, subactue 3-7 days after acute injury, chronic - 21 days or older - Correct Answer ✅ SDH Abdnormal protrusionof brain tissue through an opening when there is incrased intracranial pressue - Correct Answer ✅ Herniation

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Hemisectionof cord from penetrating injury, loss of motor on side of injury, loss of sensation on opposite side - Correct Answer ✅ Brown-Sequard oculomotor nerve runs along the edge of the tentorium and may becomme compressed against it during temporal lobe herniation, compression can cause a blown pupil - Correct Answer ✅ Temporal lobe herniation common herniation through the tentorial notch is the medial part of the temporal lobe the motor tract crosses the opposite side of the foramen magnum and results in contralateral hemiparesis - Correct Answer ✅ Uncal herniation take the highest score - Correct Answer ✅ GCS that is assymetric results from impairment of the descending sympathetic pathways, results in loss of vasomotor tone and in sympathetic innervation to the heart. Rare in injury below T6. Loss of vasomotor tone cause vasodilation of lower extremities, visceral organs, blood pools in lower extremities.

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Bradycardia. Vasopressors are required, atropine for symptomatic bradycardia - Correct Answer ✅ Neurogenic shock can mask a potentially serious injury elsewhere in the body, such as the usual signs of an acute abd - Correct Answer ✅ Inability to perceive pain in the spinal cord injured patient the veterbra at which the bones are damaged, causing injury to the spinal cord - Correct Answer ✅ Bony level of injury determined primarily by clinical exam. Frequently discrepancy between the bony and neurologic levels because of the nerve innervation points - Correct Answer ✅ Neurologic level of injury disproportionately greater loss of motor strength in the upper extremities than in the lower extremities, with varying degress of sensory loss. Common with hyperflexion injury - Correct Answer ✅ Central cord syndrome

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parapalegia and a dissociated sensory loss with a loss of pain and temporature sensation - Correct Answer ✅ Anterior cord syndrome require intubation, below C 4 consider for increased work of breathing secondary to muscle innervation changes - Correct Answer ✅ C 1 - C 4 Thermoregulartion is impaired and patient will take the temp of the room, adversely impacts bradycardic patients - Correct Answer ✅ Poikilothermic flaccid paralysis, loss of autonomic function, abscence of cutaneous and/or proprioceptive sensation, cessation of all reflex activity below site of injury - Correct Answer ✅ Spinal Shock Common in geriatric patients, hyperextension injury - Correct Answer ✅ C2 dens fracture

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axial loading injury, degree of compression affects stability, thoracic and lumbar spine usually affected - Correct Answer ✅ Compression fractures fracturing in outward pattern, may impinge cord, can have compression and cord compression - Correct Answer ✅ Burst fracture Usually L1-2, teardrop fracture, may result in paraplegia, and small bowel injury from lap belt compression and lumbar spine - Correct Answer ✅ Chance fracture spinal cord injury without radiographic abnormality, common in PEDS, dislocation with spontaneous relocation, cord injury evident, imaging negative - Correct Answer ✅ SCIWORA uncontrolled, massive sympathetic reflex to noxious stimuli, below level of lesion - Correct Answer ✅ Autonomic dysreflexia

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blood in anterior chamber of eye, prevent rebleeding, bedrest, limited activity, HOB elevated, cycloplegic agents - atropine gtts, may need patch - Correct Answer ✅ Hyphema minimize additional damage, shield w/o pressure, eye patches contraindicated, anticipate need for OR - Correct Answer ✅ Open Globe Diplopia, can cause eye to look upward secondary to muscle/nerve impigement, emergency surgical repair indicated, delays increase risk of vision loss - Correct Answer ✅ Orbital blowout fracture transverse fx between maxillary and orbital floor, may include maxillary sinuses. Lower maxilla and teeth are mobile or floating but nose and midface stable. May have trismus, malocclusion. Check for mandible fx. - Correct Answer ✅ LeFort I includs central maxilla, nasal area, ethmoid bones, tripod shape, grasping front teeth and palate causes movement to nose and upper lip w/o movement to orbital complex, caved

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in appearance, edema, subconjunctival hemorrhage and epistaxis, early intubation for airway protection. CSF presence - rhinorrhea suggests open skull fx - Correct Answer ✅ Lefort II complete craniofacial dysfunction, associated with massive soft tissue, ocular injuries, TBI, skull injuries, cribiform plate and dural tears, rocking mxillar moves the entire face - Correct Answer ✅ LeFort III separation of all three major attachments of the zygoma to the rest of the face - Correct Answer ✅ Tripod fx complex fractures of zygoma and orbital floor, pain, trismus, diplopia, numbness to upper lip, lower lid and bilateral nasal area, surgical repair indicated - Correct Answer ✅ Orbigozygomatic fracture internal jugular vein and internal carotid artery most commonly injured - Correct Answer ✅ Neck trauma

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highest mortality, angle of mandible to base of skull, difficult to assess, and exploration can increase mortality - Correct Answer ✅ Zone I neck trauma mid portion of neck, injuries apparent on exam, most carotid injuries occur here, manage by observation. - Correct Answer ✅ Zone II neck trauma clavicles and sternal notch to cricoid cartilage. hard to assess surgically as so high at skull base. Diagnosis essential as infection can occur and impact mortality after 24 hours. Embolization very valuable, exploration can damage cranial nerves. Angiography to delineate site of injury - Correct Answer ✅ Zone III Neck trauma airway obstruction, pulsatile bleeding, expanding hematoma, unresponsive, extensive subcutaneous emphysema - Correct Answer ✅ S/S of emergency intervention in neck trauma voice change, wide mediatstinum, hemoptysis, hematemesis, dysphonia/dysphagia, drooling, bloody sputum, horner's

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syndrome, pain with turning neck - Correct Answer ✅ s/s of neck trauma needing more diagnostics a contracted pupil, drooping upper eyelid, and local inability to sweat on one side of the face, caused by damage to sympathetic nerves on that side of the neck - Correct Answer ✅ Horner's syndrome stabiltize airway, pressure control for bleeding, subclavial injury needs IV on opposite site, consider permissive hypotension, repair vs ligation, shunting, embolization, ligation, antithrombotic - Correct Answer ✅ Neck trauma treatment CXR mandated for zone I, CT most accepted, CT angiogram - excellent for laryngeal and tracheal injuries, as reliable as arteriography. Arteriogram - considered gold standard, invasive with risk of complications, contast load but embolization can happen at the same time. - Correct Answer ✅ Neck trauma diagnostic testing

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LeFort fractures, basilar skull fracture involving carotid canal, diffuse axonal injury with GCS < 6, cervical fracture, near hanging/anxoic brain injury, seatbelt abrasion with significant swelling/altered mental status/ TBI, necrotizing infections - Correct Answer ✅ Associated injuries with neck trauma Suspected injuries: Capone do, anterior flail chest, myocardial contusion, pneumothorax, traumatic aortic disruption, fracturednspleennornkiver, posterior fracture/dislocation of hip and/or knee - Correct Answer ✅ Frontal impact Suspect injuries: contra lateral neck sprain, Capone go, lateral flail chest, pneumothorax, traumatic aortic disruption, diaphragmatic disruptive, fractured spleen liver or kidney, fix Pelvis or scetabulum - Correct Answer ✅ Side impact Cspine injury or soft tissue to neck - Correct Answer ✅ Rear impact