TNCC Written Exam 2024: Trauma Care Questions and Answers, Exams of Nursing

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TNCC Written Exam 2024

What are the late signs of breathing compromise? - ANS - Tracheal deviation

• JVD What are signs of ineffective breathing? - ANS - AMS
• Cyanosis, especially around the mouth
• Asymmetric expansion of chest wall
• Paradoxical movement of the chest wall during inspiration and expiration
• Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing
• Sucking chest wounds
• Absent or diminished breath sounds
• Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated
• Anticipate definitive airway management to support ventilation. Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? - ANS A tight- fitting nonrebreather mask at 12-15 lpm. What intervention should be done if a pt presents with effective circulation? - ANS - Insert 2 large caliber IV's
• Administer warmed isotonic crystalloid solution at an appropriate rate What are signs of ineffective circulation? - ANS - Tachycardia
• AMS
• Uncontrolled external bleeding
• Pale, cool, moist skin
• Distended or abnormally flattened external jugular veins

• Distant heart sounds What are the interventions for Effective/Ineffective Circulation? - ANS - Control any uncontrolled external bleeding by:
• Applying direct pressure over bleeding site
• Elevating bleeding extremity
• Applying pressure over arterial pressure points
• Using tourniquet (last resort).
• Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution
• Use warmed solution
• Use pressure bags to increase speed of IVF infusion
• Use blood administration tubing for possible administration of blood
• Use rapid infusion device based on protocol
• Use NS 0.9% in same tubing as blood product
• IV = surgical cut-down, central line, or both.
• Blood sample to determine ABO and Rh group
• IO in sternum, legs, arms or pelvis
• Administer blood products
• PASG (without interfering with fluid resuscitation) What are factors that contribute to ineffective ventilation? - ANS - AMS
• LOC
• Neurologic injury
• Spinal Cord Injury
• Intracranial Injury
• Blunt trauma

POSTINTUBATION MANAGEMENT:

• Secure ET tube
• Set ventilator settings
• Obtain Chest x-ray
• Continue to medicate
• Recheck VS and pulse oxtimetry What is a Combitube? - ANS A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult. What is a Laryngeal Mask Airway? - ANS Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords. What is Needle Cricothyrotomy - ANS Percutaneous transtracheal ventilation. (temporary) Complications include:
• inadequate ventilation causing hypoxia
• hematoma formation
• esophageal perforation
• aspiration
• thyroid perforation
• subcutaneous emphysema

What is Surgical Cricothyrotomy? - ANS Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated. Complications include:

• Aspiration
• Hemorrhage or hematoma formation or both
• Lac to trachea or esophagus
• Creation of a false passage
• Laryngeal stenosis How do you confirm ET Tube/Alternative Airway Placement? - ANS - Visualization of the chords
• Using bronchoscope to confirm placement
• Listening to breath sounds over the epigastrum and chest walls while ventilating the pt
• CO2 detector
• Esophageal detection device
• Chest x-ray How do you inspect the chest for adequate ventilation? - ANS Observe:
• mental status
• RR and pattern
• chest wall symmetry
• any injuries
• patient's skin color (cyanosis?)
• JVD or tracheal deviation? (Tension pneumothorax)

Explain Hypovolemic Shock. - ANS Most common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn). Some causes:

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

Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities. What is vascular response? - ANS As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP. What is renal response? - ANS Renal ischemia activates release of renin. Kidneys do not receive adequate blood supply, renin is release into circulation. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. Angiotensin-converting enzyme from the lungs converts into angiotensin II. Angiotensin II causes:

• Vasoconstriction of arterioles and some veins
• Stimulation of sympathetic nervous system
• Retention of water by kidneys
• Stimulation of release of aldosterone from the adrenal cortex (sodium retention hormone) *Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion. Explain adrenal gland response. - ANS When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase.

Explain Irreversible Shock. - ANS Shock uncompensated or irreversible stages will cause compromises to most body systems.

• Inadequate venous return
• inadequate cardiac filling
• decreased coronary artery perfusion
• Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage. How would you assess a pt in hypovolemic shock? - ANS (Use Initial Assessment) and then: Inspect:
• LOC
• Rate and quality of respirations
• External bleeding?
• Skin color and moisture
• Assess jugular veins and peripheral veins Auscultate:
• BP
• Pulse pressure
• Breath sounds
• Heart sounds
• Bowel sounds Percuss:
• Chest and abdomen Palpate:
• Central pulse (carotid or femoral)
• Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse

• Palpate peripheral pulses
• Palpate skin temp and moisture Diagnostic Procedures:
• Xrays and other studies
• Labs Planning and Implementation
• Oxygen
• IV's with warmed replacement fluids
• Control external bleeding with direct pressure
• Elevate LE's
• NGT
• Foley
• Monitor and pulse oximeter
• Monitor for development of coagulopathies
• Surgery? ICP is a reflection of what three volumes? What happens when one increases? - ANS 1. Brain

2. CSF
3. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful.

• Unilateral or bilateral pupillary dilation
• AsyDimmetric pupillary reactivity
• Abnormal motor posturing
• Other evidence of neurologic deterioration Define uncal herniation. - ANS The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes. Define central or transtentorial herniation. - ANS A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. Disruptions of the bony structures of the skull can result in what? - ANS Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. Also: meningitis or encephalitis or brain abscess Define Minor Head Trauma. - ANS GCS 13- Define Moderate Head Trauma - ANS Postresuscitative state with GCS 9-13. Define Severe Head Trauma. - ANS Postresuscitative state with GCS score of 8 or less. What is a concussion and its signs and symptoms? - ANS A temporary change in neurologic function that may occur as a result of minor head trauma. S/S:

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

• Transient LOC
• Lucid period lasting a few minutes to several hours
• Rapid deterioration in neurologic status
• Severe H/A
• Sleepiness
• Dizziness
• N/V
• Hemiparesis or hemiplegia on opposite side of hematoma
• Unilateral fixed and dilated pupil on same side of hematoma What is a subdural hematoma and its S/S? - ANS A focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic. Acute pt's hematoma manifest 48 hrs post injury S/S:
• Altered LOC or steady decline in LOC
• S/S of increased ICP
• Hemiparesis or hemiplegia on opposite side of hematoma
• Unilateral fixed and dilated pupil on same side of hematoma Chronic pt's " " up to 2 wks post injury
• H/A
• Progressive decrease in LOC
• Ataxia
• Incontinence

• Sz's What are intracerebral hematoma's and its S/S? - ANS Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S:
• Progressive and often rapid decline in LOC
• H/A
• Signs of increasing ICP
• Pupil abnormalities
• Contralateral hemiplegia What are the S/S of a linear skull fx? - ANS - H/A
• Possible decreased LOC What are the S/S of a depressed skull fx? - ANS - H/A
• Possible decreased LOC
• Possible open fx
• Palpable depression of skull over the fx site What are the S/S of a basilar skull fx? - ANS - H/A
• Altered LOC
• Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum)
• Facial nerve (VII) palsy
• CSF rhinorrhea or otorrhea

• Point tenderness
• Depressions or deformities
• Hematomas
• Assess all 4 extremities for:
• Motor function, muscle strength and abnormal motor posturing
• Sensory function DIAGNOSTIC PROCEDURES
• Lab Studies PLANNING AND IMPLEMENTATION
• (Initial assessment)
• Clear airway (stimulation of gag reflex can produce transient increase in ICP or vomiting with subsequent aspiration.
• Administer O2 via NRB
• Assist with early ET intubation
• Administer sedative/neuromuscular blocking agent
• Consider hyperventilation
• PaCO2 above 45 What are signs of a serious eye injury? - ANS - Visual disturbances
• Pain
• Redness and ecchymosis of the eye
• Periorbital ecchymosis
• Increased intraocular pressure What is hyphema and its S/S? - ANS Accumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV).

S/S:

• Blood in anterior chamber
• Deep, aching pain
• Mild to severe diminished visual acuity
• Increased intraocular pressure What are s/s of chemical burns to the eye? - ANS Chemical injuries require immediate intervention if it is to be preserved. S/S:
• Pain
• Corneal Opacification
• Coexisting chemical burn and swelling of lids What are S/S of penetrating trauma/open or ruptured globe? - ANS - Marked visual impairments
• Extrusion of intraocular contents
• Flattened or shallow anterior chamber
• Subconjunctival hemorrhage, hyphema
• Decreased intraocular pressure
• Restriction of extraocular movements What are the S/S of orbital fracture (orbital blowout fracture)? - ANS - Diplopia (double vision)
• Loss of vision
• Altered extraocular eye movements
• Enophthalmos (displacement of the eye backward into the socket)
• Subconjunctival hemorrhage or ecchymosis of the eyelid
• Infraorbital pain or loss of sensation