TNCC examination with verified answers, Exams of Nursing

Download TNCC examination with verified answers and more Exams Nursing in PDF only on Docsity! TNCC Examination with verified answers Affect concentration, memory, sleep, mode, and libido. Causes headaches, dizziness and nausea. CORRECT ANSWER Postconcussive Syndrome/ Mild Traumatic Brain Injury An rise in diastolic blood pressures is a sign of increasing what? CORRECT ANSWER Peripheral resistance Anxiety, confusion, restlessness, narrowing pulse pressure, tachycardia, bounding pulse, and decreasing urinary output are signs of what? CORRECT ANSWER Compensated Shock Becks Triad is a sign of what? And includes what three symptoms? CORRECT ANSWER Cardiac Tamponade; 1. Hypotension 2. JVD 3. Muffled heart sounds Benefits of the trauma nursing process CORRECT ANSWER Systematic approach to the evaluation of each trauma patient. Identifies life-threatening conditions, determines priorities of care. Burn extends into the fascia and/or muscle. What degree burn? CORRECT ANSWER Fourth degree; full thickness Cerebral Perfusion Pressure = ______-______ CORRECT ANSWER MAP - ICP Contaminated wound, granulation tissue, delayed closure with suture. This is _______ Intention. CORRECT ANSWER Tertiary Decreased level of consciousness, hypotension, narrowed pulse pressure, tachycardia with weak pulse, tachypnea, and cool, clammy, cyanotic skin are signs of what? CORRECT ANSWER Decompensated/Progressive shock Decreased/absent breath sounds ipsilaterally, JVD, hypotension, and tracheal deviation to the contralateral side (late sign) is seen with what? Can lead to what? CORRECT ANSWER Tension Pneumothorax; PEA Diaphragmatic Tears are seen with what types of injuries? CORRECT ANSWER Penetrating injuries between T4-T12, or rapid deceleration causing severe blunt trauma to the torso. Disaster Definition CORRECT ANSWER A 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. Does hypoventilation cause dilation or constriction? Increase or decrease ICP? CORRECT ANSWER Dilation and increase in ICP due to high CO2 Dysrhythmia, ischemic changes, and persistent unexplained tachycardia are signs of what? CORRECT ANSWER Myocardial contusion from Blunt Cardiac Injury Efficient production of ATP, which maintains cellular metabolic function, is seen with what type of metabolism? CORRECT ANSWER Aerobic metabolism Epidural hematoma is caused by an arterial or venous bleed? Sx are transient LOC followed by a lucid period. CORRECT ANSWER Arterial Extremity elevation AT the level of the heart is beneficial for what type of injury? CORRECT ANSWER Compartment Syndrome Fluid replacement goals/calculation CORRECT ANSWER 2mL/kg LR x TBSA% (give 1/2 over first 8 hours (minus transport time) and 1/2 over next 16 hours) Glasgow Coma Score with Mild, Moderate, and Severe TBI CORRECT ANSWER Mild = 13-15 Moderate = 9-12 Severe = 3-8 Pupils with anticholinergics such as atropine, ipratropium, and scopolamine CORRECT ANSWER large Pupils with opiates vs stimulants CORRECT ANSWER small; large Pupils with pressure on cranial nerve CORRECT ANSWER Fixed and dilated Referred pain down the left shoulder; indicative of a ruptured spleen. CORRECT ANSWER Kehr's Sign Reservoir depletion and hemorrhage cause which type of shock? CORRECT ANSWER Hypovolemic Shock Signs and symptoms similar to early signs of increased ICP but do not worsen. CORRECT ANSWER Postconcussive Syndrome/ Mild Traumatic Brain Injury Signs of what include anxiety, pleuritic chest pain, dyspnea, hypoxemia, hemoptysis, cough, orthopnea, adventitious lung sounds, decreased lung sounds, jugular vein distention, or hypotension? CORRECT ANSWER Pulmonary Embolus Signs of what include asymmetric pupillary reactivity, unilateral dilation, widening pulse pressure, abnormal motor posturing, bradycardia, and decreased respiratory effort? CORRECT ANSWER Late signs of increased ICP with Herniation Syndrome Signs of what include headache, nausea and vomiting, amnesia, behavioral changes, altered level of consciousness? CORRECT ANSWER Increased intracranial pressure Signs of what include muscle pain or weakness, dark red or brown urine, general weakness or malaise, and elevated creatinine kinase levels? CORRECT ANSWER Rhabdomyolosis Sluggish reaction of pupils is an early sign of what? CORRECT ANSWER Increasing ICP Soft, dry, red wound with intact skin that blanches with pressure. No blistering or sloughing. What degree burn? CORRECT ANSWER First degree; superficial Spinal cord injuries at C3-C5 causes loss of what nerves function, resulting in what? CORRECT ANSWER Phrenic nerve; paralyzed diaphragm and inability to breath Stages of shock CORRECT ANSWER 1. Compensatory Shock 2. Decompensatory Shock (progressive, hypotensive) 3. Irreversible Shock Subdural hematoma is caused by tearing of the ______ veins and symptoms usually present within ____ hours of the accident. CORRECT ANSWER Bridging; 72 Tachycarida, weak pulses, hypotension, cool periphery, delayed cap refill, anxiety and agitation are signs of what type of shock? Seen with what? CORRECT ANSWER Obstructive Shock; Cardiac Tamponade Tearing chest/back pain, unequal blood pressure and pulses are a sign of what? Caused by a high mechanism of injury. CORRECT ANSWER Thoracic Aortic Disruption Tertiary care facility, teaching hospital, comprehensive care from resuscitation or rehabilitation, research, injury prevention. CORRECT ANSWER Level 1 Trauma Center The cellular process in which glucose is metabolized into energy without oxygen. Energy is produced in an inefficient manner with many waste products. CORRECT ANSWER Anaerobic metabolism The cellular process in which oxygen is used to metabolize glucose. Energy is produced in an efficient manner with minimal waste products. CORRECT ANSWER Aerobic metabolism Trauma rescucitation and definitive trauma care. Specialty and rehabilitation care may not be as comprehensive, may not conduct research. CORRECT ANSWER Level 2 Trauma Center Treatment for cariogenic shock CORRECT ANSWER inotropic support, anti-dysrhythmic medications, treat myocardial infarction or other underlying cause Treatment for distributive shock CORRECT ANSWER Support ventilations, vasopressors, pain management, apply warming methods Treatment for hypovolemic shock CORRECT ANSWER Tourniquet, 1:1:1 blood products, massive transfusion protocol, TXA, surgical repair Treatment for obstructive shock CORRECT ANSWER pericardiocentesis, cardiac window, needle decompression, position pregnant patient on L side Triage colors and meanings: CORRECT ANSWER Green - minor, walking wounded Yellow - delayed Red - immediate Black - expectant, deceased Urine Output goals for fluid replacement therapy CORRECT ANSWER 0.5 mL/kg (30-50mL/hr) Vasodilation, anaphylaxis, sepsis, and spinal cord injuries cause which type of shock? CORRECT ANSWER Distributive Shock Waxy white to leathery gray to charred skin that is dry and firm with absent hair, no blanching. What degree burn? CORRECT ANSWER Third degree; full thickness Wet, waxy, red to pale skin that does not blanch, multiple sisters. What degree burn? CORRECT ANSWER Second degree; deep partial thickness