Traumatic Brain Injuries and Associated Conditions, Exams of Nursing

Download Traumatic Brain Injuries and Associated Conditions and more Exams Nursing in PDF only on Docsity!

1 / 41

TNCC Written Exam 2024 Questions with Answers

1. What are the late signs of breathing compromise?: - Tracheal deviation

• JVD

2. What are signs of ineffective breathing?: - 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.

3. Upon initial assessment, what type of oxygen should be used for a pt breathing effectively?: A tight-fitting nonrebreather mask at 12- 15 lpm.
4. What intervention should be done if a pt presents with effective circulation?- : - Insert 2 large caliber IV's

• Administer warmed isotonic crystalloid solution at an appropriate rate

5. What are signs of ineffective circulation?: - Tachycardia

• AMS
• Uncontrolled external bleeding
• Pale, cool, moist skin
• Distended or abnormally flattened external jugular veins
• Distant heart sounds

6. What are the interventions for Effective/Ineffective Circulation?: - 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

2 / 41

• 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)

7. What are factors that contribute to ineffective ventilation?: - AMS

• LOC
• Neurologic injury
• Spinal Cord Injury
• Intracranial Injury
• Blunt trauma
• Pain caused by rib fractures
• Penetrating Trauma
• Preexisting hx of respiratory diseases
• Increased age

8. What medications are used during intubation?: LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents
9. What are the Rapid Sequence Intubation Steps?: PREPARATION:

• gather equipment, staffing, etc. PREOXYGENATION:
• Use 100% O2 (prevent risk of aspiration). PRETREATMENT:
• Decrease S/E's of intubation PARALYSIS WITH INDUCTION:
• Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING:
• Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspi- ration PLACEMENT WITH PROOF
• Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts.
• After intubation, inflate the cuff

3 / 41

• Confirm tube placement w/exhaled CO detector. POSTINTUBATION MANAGEMENT:
• Secure ET tube
• Set ventilator settings
• Obtain Chest x-ray
• Continue to medicate
• Recheck VS and pulse oxtimetry

4 / 41

10. What is a Combitube?: 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.
11. What is a Laryngeal Mask Airway?: 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.
12. What is Needle Cricothyrotomy: Percutaneous transtracheal ventilation. (tem- porary) Complications include:

• inadequate ventilation causing hypoxia
• hematoma formation
• esophageal perforation
• aspiration
• thyroid perforation
• subcutaneous emphysema

13. What is Surgical Cricothyrotomy?: Making an incision in cricothyroid mem- brane 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

14. How do you confirm ET Tube/Alternative Airway Placement?: - 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

5 / 41

15. How do you inspect the chest for adequate ventilation?: Observe:

• mental status
• RR and pattern
• chest wall symmetry
• any injuries
• patient's skin color (cyanosis?)
• JVD or tracheal deviation? (Tension pneumothorax)

16. What are you looking for when auscultating lung sounds?: Absence of BS:

• Pneumothorax
• Hemothorax
• Airway Obstruction Diminished BS:
• Splinting or shallow BS may be a result of pain

17. What are you looking for when percussing the chest?: Dullness:

• hemothorax Hyperresonan ce
• Pneumothorax

18. What are you looking for when palpating the chest wall, clavicles and neck?: - Tenderness

• Swelling
• subcutaneous emphysema
• step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax.

19. What is the DOPE mnemonic?: D - Displaced tube O - Obstruction: Check secretions or pt biting tube P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing
20. Explain Hypovolemic Shock.: 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

6 / 41 intravascular space to the interstitial space (as in a burn). Some causes:

7 / 41

• Blood loss
• Burns, etc.

21. Explain Cardiogenic Shock.: 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
22. Explain Obstructive Shock.: 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 obstruc- tion to right ventricular outflow during systole, with resulting obstructive shock

23. Explain Distributive Shock.: 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 involve- ment in complete cord injuries; reflexes return with resolution of spinal shock. Septic shock from bacteremia is distributive shock. Endotoxins and other inflamma- tory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities.
24. What is vascular response?: As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of barore- ceptors. Arterioles constrict to increase TPR and BP.
25. What is renal response?: Renal ischemia activates release of renin. Kidneys do not receive adequate blood supply, renin is release into

8 / 41 circulation. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. Angiotensin-converting enzyme from the lungs converts into angiotensin II. Angiotensin II causes:

9 / 41

• 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.

26. Explain adrenal gland response.: When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. Epi stimulates receptors in heart to increase force of cardiac contraction (positive inotropy) and increase HR (positive chronotropy) to improve cardiac output, BP and tissue perfusion. Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol. Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar. Cortisol also causes renal retention of water and sodium, a compensatory mecha- nism to conserve body water.
27. Explain Hepatic Response.: Liver can store excess glucose as glycogen. As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose. In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas.
28. Explain Pulmonary Response.: Tachypnea happens for 2 reasons: 1.Maintain acid-base balance 2.Maintain increased supply of oxygen

• Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs to increase rate of ventilation. Increased RR is an

10 / 41 attempt to correct acidosis + augments oxygen supply to maximize oxygen delivery to alveoli.

11 / 41

29. Explain Irreversible Shock.: 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.

30. How would you assess a pt in hypovolemic shock?: (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

12 / 41

- NGT

• Foley

13 / 41

• Monitor and pulse oximeter
• Monitor for development of coagulopathies
• Surgery?

31. ICP is a reflection of what three volumes? What happens when one increas- es?: 1. Brain
32. 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. Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP.
33. What are the early signs and symptoms of increased ICP?: - Headache

• N/V
• Amnesia regarding events around the injury
• Altered LOC
• Restlessness, drowsiness, changes in speech, or loss of judgement

33. What are the late observable signs of symptoms of increased ICP?:

• Dilated, nonreactive pupil
• Unresponsiveness to verbal or painful stimuli
• Abnormal motor posturing patterns
• Widening pulse pressure
• Increased systolic blood pressure
• Changes in RR and pattern
• Bradycardia

34. What is Cushing's phenomenon or Cushing's Reflex?: Triad of progressive HTN, bradycardia and diminished respiratory effort.
35. What are the two types of herniation that occurs with ICP?: 1. Uncal herni- ation
36. Central or transtentorial herniation
37. Why does herniation occur? What are the symptoms?: Because of uncon- trolled increases in ICP.

14 / 41 S/E's

• Unilateral or bilateral pupillary dilation
• AsyDimmetric pupillary reactivity
• Abnormal motor posturing
• Other evidence of neurologic deterioration

37. Define uncal herniation.: 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.
38. Define central or transtentorial herniation.: A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium.
39. Disruptions of the bony structures of the skull can result in what?: Dis- placed 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
40. Define Minor Head Trauma.: GCS 13- 15
41. Define Moderate Head Trauma: Postresuscitative state with GCS 9-13.
42. Define Severe Head Trauma.: Postresuscitative state with GCS score of 8 or less.
43. What is a concussion and its signs and symptoms?: 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

44. What are the signs and symptoms of postconcussive syndrome?: - Persis- tent H/A

15 / 41

• Dizziness
• Nausea

16 / 41

• Memory impairment
• Attention deficit
• Irritability
• Insomnia
• Impaired judgement
• Loss of libido
• Anxiety
• Depression

45. What is diffuse axonal injury and its signs and symptoms?: (DAI) is wide- spread, 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:

• Immediate unconsciousness
• mild DAI, coma = 6-24 hrs
• severe DAI, coma = weeks/months or persistent vegetative state
• Elevated ICP
• Abnormal posturing
• HTN
• Hyperthermia
• Excessive sweating because of autonomic dysfunction
• Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits

46. What is a cerebral contusion and its S/S?: A common focal brain injury in which brain tissue is bruised and damaged in a local area. Mainly located in frontal and temporal lobes. May cause hemorrhage, infarction, necrosis and edema. Max effects of bleeding & edema peak 18-36 post injury. S/S:

• Alteration in LOC
• Behavior, motor or speech deficits
• Abnormal motor posturing
• Signs of increased ICP

47. What is an epidural hematoma and its S/S?: Results when a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accu- mulates rapidly:

• Compression of underlying brain
• rapid increase in ICP

17 / 41

• Decreased CBF
• Secondary brain injury

• Usually requires surgical intervention

18 / 41

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

48. What is a subdural hematoma and its S/S?: 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

49. What are intracerebral hematoma's and its S/S?: 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

50. What are the S/S of a linear skull fx?: - H/A

19 / 41

• Possible decreased LOC

20 / 41

51. What are the S/S of a depressed skull fx?: - H/A

• Possible decreased LOC
• Possible open fx
• Palpable depression of skull over the fx site

52. What are the S/S of a basilar skull fx?: - 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

53. How would you assess a pt with a cranial injury?: (Initial assessment) INSPECTION:

• Assess airway
• RR, pattern and effort
• Assess pupil size and response to light
• Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome
• Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates
• Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome
• Widely dilated pupil occasionally occurs w/direct trauma to globe of eye
• Determine if pt uses eye meds
• Abnormal posturing?
• Inspect craniofacial area for ecchymosis/contusions
• Periorbital ecchymosis
• Mastoid's process ecchymosis
• Blood behind tympanic membrane
• Inspect nose and ears for drainage
• Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF
• If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF
• Assess extraocular eye movement (Tests cranial nerves, III, IV, VI)
• Performing extraocular eye movements indicates functioning brainstem
• Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle

21 / 41

• Determine LOC with GCS PALPATION
• Palpate cranial area for:
• Point tenderness

22 / 41

• 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

54. What are signs of a serious eye injury?: - Visual disturbances

• Pain
• Redness and ecchymosis of the eye
• Periorbital ecchymosis
• Increased intraocular pressure

55. What is hyphema and its S/S?: 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

56. What are s/s of chemical burns to the eye?: Chemical injuries require imme- diate intervention if it is to be preserved. S/S:

• Pain
• Corneal Opacification
• Coexisting chemical burn and swelling of lids

57. What are S/S of penetrating trauma/open or ruptured globe?: - Marked visual impairments

23 / 41

• Extrusion of intraocular contents

24 / 41

• Flattened or shallow anterior chamber
• Subconjunctival hemorrhage, hyphema
• Decreased intraocular pressure
• Restriction of extraocular movements

58. What are the S/S of orbital fracture (orbital blowout fracture)?: - 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
• Orbital bony deformity

59. What is LeFort I fracture and its S/S?: Transverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. S/S:

• Slight swelling of maxillary area
• Possible lip lac's or fractured teeth
• Independent movement of the maxilla from rest of face
• Malocclusion

60. What is LeFort II fracture and its S/S?: Pyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. S/S:

• Massive facial edema
• Nasal swelling w/obvious fx of nasal bones
• Malocclusion
• CSF rhinorrhea

61. What is LeFort III fracture and its S/S?: Complete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible. S/S:

• Massive facial edema
• Mobility and depression of zygomatic bones
• Ecchymosis
• Anesthesia of the cheek
• Diplopia

25 / 41

• Open bite or malocclusion
• CSF rhinorrhea

62. What are the mandibular fracture S/S?: - Malocclusion

• Inability to open the mouth (trismus)
• Pain, especially on movement
• Facial asymmetry and a palpable step-off deformity
• Edema or hematoma formation at the fracture site
• Blood behind, ruptured, tympanic membrane
• Anesthesia of the lower lip

63. What are neck injury S/S?: - Dyspnea

• Hemoptysis (coughing up blood)
• Subcutaneous emphysema in neck, face, or suprasternal area
• Decreased or absent breath sounds
• Penetrating wounds or impaled objects
• Pulsatile or expanding hematoma
• Loss of normal anatomic prominence of the laryngeal region
• Bruits
• Active external bleeding
• Neurologic deficit, such as aphasia or hemiplegia
• Cranial nerve deficits
• Facial sensory or motor nerve deficits
• Dysphonia (hoarseness)
• Dysphagia (difficulty swallowing)

64. How would you assess a patient with ocular, maxillofacial and neck trau- ma?: (Initial assessment) HISTORY

• MOI?
• Acceleration/Deceleration?
• What was it caused by?
• Pt restrained? Airbags deployed? Etc.
• What are the pt's complaints?
• Pt normally wear glasses or contacts?
• Pt have hx of eye problems?
• Pt ever have eye surgery?
• Pt have visual or ocular changes associated with chronic illness? PHYSICAL INSPECTION:
• Inspect eye, orbits, face and neck
• Check for symmetry, edema, ecchymosis, ptosis, lacerations and