TNCC TRAUMA NURSING CORE
COURSE 11TH EDITION ENA TEST
BANK VERIFIED PASS
All open fractures are considered contaminated due to exposure to the environment and are at risk for
infection. These sites of injury have poor wound healing with a risk of.... - ansOSTEOMYELITIS and SEPSIS
ch. 14, p. 197
Anterior cord syndrome - ansloss of pain and temperature sensation with weakness, paresthesia, and
urinary retention
ch. 13, p. 182
AORTIC DISRUPTION - ansAssessment findings
- Fractures of sternum, first or second rib or scapula
- CARDIAC MURMURS
- BACK, CHEST PAIN
- UNEQUAL EXTREMITY PULSE STRENGTH or BLOOD PRESSURE (Significantly greater in upper
extremities)
- HYPOTENSION
- TACHYCARDIA
- SKIN CHANGES: diaphoresis, pallor, cyanosis
- PHARAPLEGIA (due to disruption of spinal perfusion from aortic injury)
- Radiograph findings include- left hemothorax, right-sided tracheal deviation, widened mediastinum
Interventions
- Prepare for surgery or angiography
- Consider massive transfusion protocol
ch. 11, p. 146
Are the lumen contents of the small bowel considered sterile? What is the pH? - ansneutral pH, and sterile
ch. 12, p. 164
As ICP rises, CPP ________, resulting in cerebral ischemia, hypoxemia, and lethal secondary insult. -
ansDECREASES
Ch. 9, p. 109
As shock progresses, primary goal of the body is to maintain perfusion to vital organs. Sympathetic
stimulation has little effect on the cerebral and coronary vessels since they are capable of autoregulation.
Cerebral autoregulation maintains a constant... - anscerebral vascular blood flow as long as the MAP is
maintained between 50-150... when autoregulation in the brain fails, perfusion becomes dependent solely
on pressure.
ch. 7, p. 78
Assess pupils for... - ansEquality, shape, and reactivity (PERRL)
ch. 5, p. 45
Assessment findings for MILD, MODERATE, and SEVERE TRAUMATIC BRAIN INJURY INCLUDE: - ansMILD
,TNCC TRAUMA NURSING CORE
COURSE 11TH EDITION ENA TEST
BANK VERIFIED PASS
- GCS 13-15
- Brief (<30 min) LOC
- POST-TRAUMATIC AMNESIA < 24 hours
- No change on neuron aging studies
MODERATE
- GCS score 9-12
- Wide variety of symptoms, including ALTERATIONS IN CONSCIOUSNESS, CONFUSION, AMNESIA, and
FOCAL NEUROLOGICAL DEFICITS
- May deteriorate to severe head injury over time
SEVERE
- GCS score <8
- Significant alterations in consciousness
- ABNORMAL PUPILLARY RESPONSE
- ABNORMAL POSTURING
Ch. 9, p. 115
Assessment findings for renal injuries include - ans- Turner sign (bruising by 11th and 12th ribs)
- Hematuria
- Frank tenderness, costovertebral angle tenderness, palpable flank mass
- Structural damage or leakage of contrast on intravenous pyelogram (IVP)
- If patient hemodyanmically unstable for CT, a single-infusion IVP can be performed at bedside followed
by complete study once patient is stable
- Positive urine dipstick for microscopic blood or leukocyte esterase
- Abnormal or elevated BUN and creatinine
90% of injuries are minor. Anticipate nephrology consultation in more severe injures; surgical repair is
required within 12 hours to salvage an ischemic kidney
ch. 12, p. 167
Assessment findings of a CHRONIC SUBDURAL HEMATOMA - ans- ALTERED or STEADY DECLINE IN LOC
- HEADACHE
- LOSS OF MEMORY or ALTERED REASONING
- MOTOR DEFICIT: CONTRALATERAL HEMIPARESIS, HEMIPLEGIA, OR ABNORMAL MOTOR POSTURING OR
ATAXIA
- APHASIA
- IPSILATERAL UNILATERAL FIXED and DILATED PUPIL
- INCONTINENCE
- SEIZURES
Ch. 9, p. 114
Assessment findings of a DIFFUSE INJURY - ansInjuries that occur over a wide spread area, not always
identifiable on CT because damage involves contusions or hearing and stretching of micro vascular, not a
localized hematoma. These injuries commonly follow a direct blow to the head and are often sports-
related. Patients can have varying degrees of symptoms that last minutes to hours. Assessment findings
include:
- TRANSIENT LOC
,TNCC TRAUMA NURSING CORE
COURSE 11TH EDITION ENA TEST
BANK VERIFIED PASS
- HEADACHE, DIZZINESS
- NAUSEA, VOMITING
- CONFUSION, DISORIENTATION
- MEMORY LOSS and CONCENTRATION DIFFICULTY
- IRRITABILITY and FATIGUE
Ch. 9, p. 115
Assessment findings of a EPIDURAL HEMATOMA - ans- TRANSIENT LOC followed by lucid period lasting
minutes to hours
- HEADACHE, DIZZINESS
- NAUSEA, VOMITING
- CONTRALATERAL HEMIPARESIS
- HEMIPLEGIA
- ABNORMAL MOTOR POSTURING (FLEXION/EXTENSION)
Extension is associated with brainstem HERNIATION and poor outcomes
- IPSILATERAL UNILATERAL FIXED, DILATED PUPIL
- RAPID DETERIORATION IN NEURO STATUS
Ch. 9, p. 114
Assessment findings of a HERNIATION SYNDROME - ans- ASYMMETRIC PUPILLARY REACTIVITY
- UNILATERAL or BILATERAL PUPILLARY DILATION
- ABNORMAL MOTOR POSTURING
- other evidence of neurologic deterioration (loss of normal, reflexes, paralysis, or change in LOC)
Ch. 9, p. 115
Assessment findings of a INTRACEREBRAL HEMATOMA - ans- PROGRESSIVE, RAPID DECLINE IN LOC
- HEADACHE
- SIGNS OF INCREASING ICP
- PUPIL ABNORMALITIES
- CONTRALATERAL HEMIPARESIS
- HEMIPLEGIA
- ABNORMAL POSTURING
Ch. 9, p. 114
Assessment findings of an ACUTE SUBDURAL HEMATOMA - ans- SEVERE HEADACHE
- CHANGES IN LOC
- IPSILATERAL DILATED or NONREACTIVE PUPIL
- CONTRALATERAL HEMIPARESIS
Ch. 9, p. 114
Assessment findings of DIFFUSE AXONAL INJURY - ans- UNCONSCIOUSNESS
Mild DAI lasts 6-24 hrs
Severe DAI lasts weeks to months
- INCREASED ICP
- ABNORMAL POSTURING
- HTN (systolic BP between 140-160)
- HYPERTHERMIA (104-105 F)
, TNCC TRAUMA NURSING CORE
COURSE 11TH EDITION ENA TEST
BANK VERIFIED PASS
- EXCESSIVE SWEATING
- MILD TO SEVERE MEMORY LOSS; COGNITIVE, BEHAVIORAL, and INTELLECTUAL DEFICITS
Ch. 9, p. 116
AXIAL LOADING - ansetiology/cause- direct force transmitted along the length of vertebral column
rest of injury- deformity of vertebral column, secondary edema of spinal cord resulting in neurologic
effects
example- diver striking head on bottom of pool
ch. 13, p. 179
Because calcium is a vital part of the clotting casade, hypocalcemia, as a result of a massive transfusion,
can actually worsen hypovolemic shock by... - ansPermitting continued bleeding
Signs of hypocalemia include- dysrhythmias, muscle tremors, and seizures
ch. 7, p. 81
BLUNT ESOPHAGEAL INJURY - ansInjury to esophagus, rare, results form blunt trauma
Assessment findings include
- AIR in MEDIASTINUM with possible widening
- CONCURRENT LEFT PNEUMOTHORAX or HEMOTHORAX
- ESOPHAGEAL MATTER IN CHEST TUBE
- SUBCUTANEOUS EMPHYSEMA
Interventions
- Prepare for surgery
Ch. 11, p. 143
Brown-squared syndrome - ansContralateral loss of pain and temperature sensation and ipsilateral
paralysis with reduced touch sensation
ch. 13, p. 182
CARDIAC TAMPONADE - ansAssessment findings
Beck's Triad- HYPOTENSION, MUFFLED HEART SOUNDS, DISTENDED NECK VEINS
- CHEST PAIN
- TACHYCARDIA
- DYSPNEA
- CYANOSIS
- Pulsus paradoxus greater than 10 mm Hg
Interventions
- Prepare for pericardial decompression
- 3 to 4 cm incision made just left of xiphoid process
- Needle percardiocentesis may also be used to relieve symptoms of cardiac tamponade but its only
temporary solution
COURSE 11TH EDITION ENA TEST
BANK VERIFIED PASS
All open fractures are considered contaminated due to exposure to the environment and are at risk for
infection. These sites of injury have poor wound healing with a risk of.... - ansOSTEOMYELITIS and SEPSIS
ch. 14, p. 197
Anterior cord syndrome - ansloss of pain and temperature sensation with weakness, paresthesia, and
urinary retention
ch. 13, p. 182
AORTIC DISRUPTION - ansAssessment findings
- Fractures of sternum, first or second rib or scapula
- CARDIAC MURMURS
- BACK, CHEST PAIN
- UNEQUAL EXTREMITY PULSE STRENGTH or BLOOD PRESSURE (Significantly greater in upper
extremities)
- HYPOTENSION
- TACHYCARDIA
- SKIN CHANGES: diaphoresis, pallor, cyanosis
- PHARAPLEGIA (due to disruption of spinal perfusion from aortic injury)
- Radiograph findings include- left hemothorax, right-sided tracheal deviation, widened mediastinum
Interventions
- Prepare for surgery or angiography
- Consider massive transfusion protocol
ch. 11, p. 146
Are the lumen contents of the small bowel considered sterile? What is the pH? - ansneutral pH, and sterile
ch. 12, p. 164
As ICP rises, CPP ________, resulting in cerebral ischemia, hypoxemia, and lethal secondary insult. -
ansDECREASES
Ch. 9, p. 109
As shock progresses, primary goal of the body is to maintain perfusion to vital organs. Sympathetic
stimulation has little effect on the cerebral and coronary vessels since they are capable of autoregulation.
Cerebral autoregulation maintains a constant... - anscerebral vascular blood flow as long as the MAP is
maintained between 50-150... when autoregulation in the brain fails, perfusion becomes dependent solely
on pressure.
ch. 7, p. 78
Assess pupils for... - ansEquality, shape, and reactivity (PERRL)
ch. 5, p. 45
Assessment findings for MILD, MODERATE, and SEVERE TRAUMATIC BRAIN INJURY INCLUDE: - ansMILD
,TNCC TRAUMA NURSING CORE
COURSE 11TH EDITION ENA TEST
BANK VERIFIED PASS
- GCS 13-15
- Brief (<30 min) LOC
- POST-TRAUMATIC AMNESIA < 24 hours
- No change on neuron aging studies
MODERATE
- GCS score 9-12
- Wide variety of symptoms, including ALTERATIONS IN CONSCIOUSNESS, CONFUSION, AMNESIA, and
FOCAL NEUROLOGICAL DEFICITS
- May deteriorate to severe head injury over time
SEVERE
- GCS score <8
- Significant alterations in consciousness
- ABNORMAL PUPILLARY RESPONSE
- ABNORMAL POSTURING
Ch. 9, p. 115
Assessment findings for renal injuries include - ans- Turner sign (bruising by 11th and 12th ribs)
- Hematuria
- Frank tenderness, costovertebral angle tenderness, palpable flank mass
- Structural damage or leakage of contrast on intravenous pyelogram (IVP)
- If patient hemodyanmically unstable for CT, a single-infusion IVP can be performed at bedside followed
by complete study once patient is stable
- Positive urine dipstick for microscopic blood or leukocyte esterase
- Abnormal or elevated BUN and creatinine
90% of injuries are minor. Anticipate nephrology consultation in more severe injures; surgical repair is
required within 12 hours to salvage an ischemic kidney
ch. 12, p. 167
Assessment findings of a CHRONIC SUBDURAL HEMATOMA - ans- ALTERED or STEADY DECLINE IN LOC
- HEADACHE
- LOSS OF MEMORY or ALTERED REASONING
- MOTOR DEFICIT: CONTRALATERAL HEMIPARESIS, HEMIPLEGIA, OR ABNORMAL MOTOR POSTURING OR
ATAXIA
- APHASIA
- IPSILATERAL UNILATERAL FIXED and DILATED PUPIL
- INCONTINENCE
- SEIZURES
Ch. 9, p. 114
Assessment findings of a DIFFUSE INJURY - ansInjuries that occur over a wide spread area, not always
identifiable on CT because damage involves contusions or hearing and stretching of micro vascular, not a
localized hematoma. These injuries commonly follow a direct blow to the head and are often sports-
related. Patients can have varying degrees of symptoms that last minutes to hours. Assessment findings
include:
- TRANSIENT LOC
,TNCC TRAUMA NURSING CORE
COURSE 11TH EDITION ENA TEST
BANK VERIFIED PASS
- HEADACHE, DIZZINESS
- NAUSEA, VOMITING
- CONFUSION, DISORIENTATION
- MEMORY LOSS and CONCENTRATION DIFFICULTY
- IRRITABILITY and FATIGUE
Ch. 9, p. 115
Assessment findings of a EPIDURAL HEMATOMA - ans- TRANSIENT LOC followed by lucid period lasting
minutes to hours
- HEADACHE, DIZZINESS
- NAUSEA, VOMITING
- CONTRALATERAL HEMIPARESIS
- HEMIPLEGIA
- ABNORMAL MOTOR POSTURING (FLEXION/EXTENSION)
Extension is associated with brainstem HERNIATION and poor outcomes
- IPSILATERAL UNILATERAL FIXED, DILATED PUPIL
- RAPID DETERIORATION IN NEURO STATUS
Ch. 9, p. 114
Assessment findings of a HERNIATION SYNDROME - ans- ASYMMETRIC PUPILLARY REACTIVITY
- UNILATERAL or BILATERAL PUPILLARY DILATION
- ABNORMAL MOTOR POSTURING
- other evidence of neurologic deterioration (loss of normal, reflexes, paralysis, or change in LOC)
Ch. 9, p. 115
Assessment findings of a INTRACEREBRAL HEMATOMA - ans- PROGRESSIVE, RAPID DECLINE IN LOC
- HEADACHE
- SIGNS OF INCREASING ICP
- PUPIL ABNORMALITIES
- CONTRALATERAL HEMIPARESIS
- HEMIPLEGIA
- ABNORMAL POSTURING
Ch. 9, p. 114
Assessment findings of an ACUTE SUBDURAL HEMATOMA - ans- SEVERE HEADACHE
- CHANGES IN LOC
- IPSILATERAL DILATED or NONREACTIVE PUPIL
- CONTRALATERAL HEMIPARESIS
Ch. 9, p. 114
Assessment findings of DIFFUSE AXONAL INJURY - ans- UNCONSCIOUSNESS
Mild DAI lasts 6-24 hrs
Severe DAI lasts weeks to months
- INCREASED ICP
- ABNORMAL POSTURING
- HTN (systolic BP between 140-160)
- HYPERTHERMIA (104-105 F)
, TNCC TRAUMA NURSING CORE
COURSE 11TH EDITION ENA TEST
BANK VERIFIED PASS
- EXCESSIVE SWEATING
- MILD TO SEVERE MEMORY LOSS; COGNITIVE, BEHAVIORAL, and INTELLECTUAL DEFICITS
Ch. 9, p. 116
AXIAL LOADING - ansetiology/cause- direct force transmitted along the length of vertebral column
rest of injury- deformity of vertebral column, secondary edema of spinal cord resulting in neurologic
effects
example- diver striking head on bottom of pool
ch. 13, p. 179
Because calcium is a vital part of the clotting casade, hypocalcemia, as a result of a massive transfusion,
can actually worsen hypovolemic shock by... - ansPermitting continued bleeding
Signs of hypocalemia include- dysrhythmias, muscle tremors, and seizures
ch. 7, p. 81
BLUNT ESOPHAGEAL INJURY - ansInjury to esophagus, rare, results form blunt trauma
Assessment findings include
- AIR in MEDIASTINUM with possible widening
- CONCURRENT LEFT PNEUMOTHORAX or HEMOTHORAX
- ESOPHAGEAL MATTER IN CHEST TUBE
- SUBCUTANEOUS EMPHYSEMA
Interventions
- Prepare for surgery
Ch. 11, p. 143
Brown-squared syndrome - ansContralateral loss of pain and temperature sensation and ipsilateral
paralysis with reduced touch sensation
ch. 13, p. 182
CARDIAC TAMPONADE - ansAssessment findings
Beck's Triad- HYPOTENSION, MUFFLED HEART SOUNDS, DISTENDED NECK VEINS
- CHEST PAIN
- TACHYCARDIA
- DYSPNEA
- CYANOSIS
- Pulsus paradoxus greater than 10 mm Hg
Interventions
- Prepare for pericardial decompression
- 3 to 4 cm incision made just left of xiphoid process
- Needle percardiocentesis may also be used to relieve symptoms of cardiac tamponade but its only
temporary solution
