Trauma Nursing Core Course (TNCC) 9th Edition: Key Concepts and Interventions, Exams of Nursing

Download Trauma Nursing Core Course (TNCC) 9th Edition: Key Concepts and Interventions and more Exams Nursing in PDF only on Docsity! TNCC 9th Edition TNP What does the J stand for at the end of the secondary survery? - just keep evaluating - vipp What does VIPP stand for? - vital signs, injuries/interventions, primary survey, pain During the head-to-toe, where would you find Grey-Turner's sign? - flank During the head-to-toe, where would you find Cullen's sign? - umbilicus What is sometimes deferred at the end of the head-to-toe? - inspecting 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? - AFTER head-to-toe, BEFORE J (VIPP) What three items are obtained during the pertinent history assessment? - Medical records, prehospital report, SAMPLE What are examples of nonpharmacologic measures? (must identify at least one during testing) - Distraction, family presence, padding bony prominences, repositioning, splinting, verbal reassurance For whom is capnography highly recommended? - all patients In step M of "Get Adjuncts", what else might be indicated besides cardiac monitor? - EKG In Step 16 of "Exposure and Environment", you must name at least one of these interventions: - blankets, room temp increase, warmed fluids, warming lights At what point PRIOR TO the head-to-toe is the patient inspected for obvious injuries? - In Step 15 of "Exposure and Environment" In Step 13 of "Disability", what is assessed if pt is altered? - glucose To assess circulation, you must do these two main tasks: - 1. 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? - intervene as appropriate and reassess What three assessments must be done if the patient is intubated? - 1. 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: - Breath 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 A patient involved in a high-speed rollover is complaining of increased difficulty breathing. There is a small penetrating wound to the sixth intercostal space in the left lateral chest. Which finding is most consistent with an injury to the diaphragm? A.Severe left-sided abdominal pain B.Bowel sounds heard in the left lower chest C.Pain radiating to the left shoulder. D.Decreased breath sounds on the left side - Bowel sounds heard in the left lower chest A patient has been in the emergency department for several hours waiting to be admitted. They sustained multiple rib fractures and a femur fracture after a fall. The patient has been awake, alert, and complaining of leg pain. Their spouse reported that the patient suddenly became anxious and confused. Upon reassessment, the patient is restless, with respiratory distress and petechiae to his neck. The patient is exhibiting signs and symptoms most commonly associated with which of the following co - fat embolism Three adults present at different times during a one-hour period with a high fever, fatigue, and headache. All three patients have a rash which started on their mouth, face, and arms with progression to the chest and abdomen. They all visited the same grocery store within the last week. What is the most appropriate intervention from triage for these patients? A.Move them to a decontamination area B.Mask the patients and send them to the waiting room C.Immediately initiate isolation precautions - Immediately initiate isolation precautions 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? A.Oculomotor nerve palsy B.Globe rupture C.Retrobulbar hematoma D.Retinal detachment - Globe rupture 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 D.Numbness to the perianal area - Voluntary anal sphincter tone While caring for a trauma patient in the emergency department, what finding raises suspicion of a complete spinal cord injury? A.Weakness in the lower extremities B.Urinary incontinence C.Sacral sparing D.Spastic paralysis of the legs - urinary incontinence Which blood pressure finding is associated with early or compensated hypovolemic shock? A.Rising systolic B.Rising diastolic C.Decreasing diastolic D.Decreasing systolic - B. Rising diastolic Which of the following is true about the log-roll maneuver? A.It causes less spinal motion than the lift-and-slide maneuver B.It is recommended for patients with unstable pelvic fractures C.It should be avoided with a suspected spine injury prior to imaging D.It decreases the risk of hemorrhage from unstable pelvic injuries - It should be avoided with a suspected spine injury prior to imaging A patient has uncontrolled bleeding from a wound to his right upper extremity. What is the priority intervention? A.Initiate two intravenous access sites B.Place the patient on supplemental oxygen C.Apply direct pressure to the wound D.Use a tourniquet to control the bleeding - C.Apply direct pressure to the wound Which of the following situations could cause functional grief? A.Inability to live at home B.Amputation of a limb C.Loss of one's self-image D.Destruction of the patient's car - B.Amputation of a limb Using the American College of Surgeons screening guidelines, what assessment finding would prompt the nurse to prepare a patient for cervical spine imaging? A.Alert with no neurologic deficits B.Multiple abrasions to the extremities C.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 - C.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 - B.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 - D.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 - B.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 - C.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 - B.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 - D.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 - D.Moral injury What is the rationale for obtaining a serum lactate level during the initial assessment of a trauma patient? A.Measures oxygenation and ventilation B.Assesses the degree of alkalosis and base deficit C.Gauges end-organ perfusion and tissue hypoxia D.Determines the underlying cause of shock - C.Gauges end-organ perfusion and tissue hypoxia What is the most important consideration during the initial assessment when caring for an older adult who has sustained serious injuries? D.It has high sensitivity in pediatric patients for identifying fluid in the peritoneum - B.It can be used in hypotensive patients too unstable for computed tomography scan What is the priority intervention for a child who has been diagnosed with an atlanto-occipital dislocation following a high-speed motor vehicle collision? A.Initiating a second large caliber intravenous line B.Maintaining spinal motion restriction C.Placing the patient on pulse oximetry D.Turning the patient to remove the backboard - B.Maintaining spinal motion restriction What position optimizes ventilation in the obese patient with a lumbar fracture? A.Reverse Trendelenburg B.Supine C.Prone D.Fowler's - A.Reverse Trendelenburg During the primary survey of an unconscious patient with multi-system trauma, the nurse notes snoring respirations. Which priority nursing intervention should be performed next? 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 - D.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 - C.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 - A.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 - C.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 - B.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 - C.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 - C.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?