TNCC NOTES FOR WRITTEN EXAM LATEST 2024-2025 |TEST
BANK|100% COMPLETE Pass A+
What are intracerebral hematoma's and its S/S? - ansOccur 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 neck injury S/S? - ans- 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)
What are S/S of a rib fracture? - ans- Dyspnea
- Localized pain on movement, palpation, or inspiration
- Pt assumes position intended to splint chest wall to reduce pain
- Chest wall ecchymosis or sternal contusion
- Bony crepitus or deformity
What are S/S of a ruptured diaphragm? - ans(Anything below the nipple line and should be evaluated for
potential diaphragmatic injury).
- Dyspnea or orthopnea
- Dysphagia
- Abdominal pain
- Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign)
- Bowel sounds heard in lower middle chest
- Decreased breath sounds on injured side
What are s/s of chemical burns to the eye? - ansChemical 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
,TNCC NOTES FOR WRITTEN EXAM LATEST 2024-2025 |TEST
BANK|100% COMPLETE Pass A+
- Restriction of extraocular movements
What are S/S with blunt cardiac injury? - ans"Cardiac contusion" or "concussion." Common with MVC or
falls from heights.
- ECG (sinus tach, PVC's, AV blocks)
- Chest pain
- Chest wall ecchymosis
What are S/S with tracheobronchial injury? - ansBlunt trauma. "Clothesline-type" injuries.
- Dyspnea, tachypnea
- Hoarseness
- Hemoptysis
- Subcutaneous emphysema in neck, face, or suprasternal area
- Decreased or absent breath sounds
- S/S of airway obstruction
What are signs of a serious eye injury? - ans- Visual disturbances
- Pain
- Redness and ecchymosis of the eye
- Periorbital ecchymosis
- Increased intraocular pressure
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.
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 early signs and symptoms of increased ICP? - ans- Headache
- N/V
- Amnesia regarding events around the injury
- Altered LOC
- Restlessness, drowsiness, changes in speech, or loss of judgement
What are the interventions for Disability? - ans- If assessment indicates a decreased LOC, conduct further
investigation during secondary focused assessments
- If pt is not alert or verbal, continue to monitor for any compromise to ABC's
- If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation.
What are the interventions for Effective/Ineffective Circulation? - ans- Control any uncontrolled external
bleeding by:
- Applying direct pressure over bleeding site
, TNCC NOTES FOR WRITTEN EXAM LATEST 2024-2025 |TEST
BANK|100% COMPLETE Pass A+
- 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 the late observable signs of symptoms of increased ICP? - ans- 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
What are the late signs of breathing compromise? - ans- Tracheal deviation
- JVD
What are the mandibular fracture S/S? - ans- 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
What are the most common type of injury associated with chest trauma? - ansblunt; MVC's. Penetrating;
firarm injuries or stabbings
What are the nursing interventions for a patient with a maxillofacial or neck injury? - ans- Administer
oxygen
- For facial trauma, place pt in high-fowler's position if no spinal injury is present.
- Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected
- Monitor for progressive airway assessment
- Prepare for intubation, PRN.
- Cannulate 2 large IV's, initiate isotonic crystalloid IV solution
- Control external bleeding w/direct pressure
- Monitor for continued bleeding + expanding hematomas
- Apply cold compresses to face to minimize edema
- Assist w/repair of oral lac's, PRN
- Admin antibiotics
- Stabilize impaled objects
- Admin analgesic meds
What are the nursing interventions for a pt with an ocular injury? - ans- Assess visual acuity & reassess
BANK|100% COMPLETE Pass A+
What are intracerebral hematoma's and its S/S? - ansOccur 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 neck injury S/S? - ans- 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)
What are S/S of a rib fracture? - ans- Dyspnea
- Localized pain on movement, palpation, or inspiration
- Pt assumes position intended to splint chest wall to reduce pain
- Chest wall ecchymosis or sternal contusion
- Bony crepitus or deformity
What are S/S of a ruptured diaphragm? - ans(Anything below the nipple line and should be evaluated for
potential diaphragmatic injury).
- Dyspnea or orthopnea
- Dysphagia
- Abdominal pain
- Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign)
- Bowel sounds heard in lower middle chest
- Decreased breath sounds on injured side
What are s/s of chemical burns to the eye? - ansChemical 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
,TNCC NOTES FOR WRITTEN EXAM LATEST 2024-2025 |TEST
BANK|100% COMPLETE Pass A+
- Restriction of extraocular movements
What are S/S with blunt cardiac injury? - ans"Cardiac contusion" or "concussion." Common with MVC or
falls from heights.
- ECG (sinus tach, PVC's, AV blocks)
- Chest pain
- Chest wall ecchymosis
What are S/S with tracheobronchial injury? - ansBlunt trauma. "Clothesline-type" injuries.
- Dyspnea, tachypnea
- Hoarseness
- Hemoptysis
- Subcutaneous emphysema in neck, face, or suprasternal area
- Decreased or absent breath sounds
- S/S of airway obstruction
What are signs of a serious eye injury? - ans- Visual disturbances
- Pain
- Redness and ecchymosis of the eye
- Periorbital ecchymosis
- Increased intraocular pressure
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.
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 early signs and symptoms of increased ICP? - ans- Headache
- N/V
- Amnesia regarding events around the injury
- Altered LOC
- Restlessness, drowsiness, changes in speech, or loss of judgement
What are the interventions for Disability? - ans- If assessment indicates a decreased LOC, conduct further
investigation during secondary focused assessments
- If pt is not alert or verbal, continue to monitor for any compromise to ABC's
- If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation.
What are the interventions for Effective/Ineffective Circulation? - ans- Control any uncontrolled external
bleeding by:
- Applying direct pressure over bleeding site
, TNCC NOTES FOR WRITTEN EXAM LATEST 2024-2025 |TEST
BANK|100% COMPLETE Pass A+
- 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 the late observable signs of symptoms of increased ICP? - ans- 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
What are the late signs of breathing compromise? - ans- Tracheal deviation
- JVD
What are the mandibular fracture S/S? - ans- 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
What are the most common type of injury associated with chest trauma? - ansblunt; MVC's. Penetrating;
firarm injuries or stabbings
What are the nursing interventions for a patient with a maxillofacial or neck injury? - ans- Administer
oxygen
- For facial trauma, place pt in high-fowler's position if no spinal injury is present.
- Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected
- Monitor for progressive airway assessment
- Prepare for intubation, PRN.
- Cannulate 2 large IV's, initiate isotonic crystalloid IV solution
- Control external bleeding w/direct pressure
- Monitor for continued bleeding + expanding hematomas
- Apply cold compresses to face to minimize edema
- Assist w/repair of oral lac's, PRN
- Admin antibiotics
- Stabilize impaled objects
- Admin analgesic meds
What are the nursing interventions for a pt with an ocular injury? - ans- Assess visual acuity & reassess
