TNCC Trauma Nursing Core Course 15th
Edition ENA Test Bank |Graded A+ pass
Explain pancreatic injuries - ans- Penetrating pancreatic injuries often sustain concurrent duodenal
injuries
- Less than 10% of those with a pancreatic injury will have a single-system injury
- Suspicion for spinal fractures when the pancreas is crushed between anterior abdominal wall and spinal
column
ch. 12, p. 164
Explain pericardial tamponade and its assessment findings - ansWhen there is a rapid accumulation of
blood in pericardial sac, resulting in compression of heart making it difficult for heart to fill during
diastole, causing decreased cardiac output.
Assessment findings include:
- HYPOTENSION
- TACHYCARDIA
- MUFFLED HEART SOUNDS
- NECK VEIN DISTENTION
Ch. 11, p. 141
Explain RETROBULBAR HEMATOMA - ansTRUE OPHTHALMOLOGIC EMERGENCY
Hemorrhage into space behind globe; bleeding causes increased pressure behind globe causing elevation
in IOP that compresses optic nerve and blood vessels. Early recognition is imperative to save vision.
Assessment findings include:
- SEVERE PAIN
- DECREASED VISION
- REDUCED EYE MOVEMENT
- IOP > 40 mm Hg
Treatment include:
- Emergency decompression via LATERAL CANTHOTOMY indicated with IOP > 40 mm Hg
Ch. 10, p. 131
Explain stable and unstable pelvic fractures - ansStable- does not involve pelvic ring or there is minial
displacement of pelvic ring
Unstable fractures- 2 or more fractures of pelvic ring that have outward rotational displacement
ch. 12, p. 166
Explain the AVPU mnemonic - ansUsed to quickly assess patient's level of alertness
A- ALERT
(If any of the responses below are elicited at this point, the airway may be compromised)
V- responds to VERBAL stimuli, airway adjunct may be needed to keep tongue from obstructing airway
P - responds to PAIN.
U- UNRESPONSIVE. If patient is unresponsive, announce loudly to the team and direct someone to check
if the patient has a pulse while assessing if the cause of the problem is the airway. Consider reprioritizing
the assessment priority to <C>ABC
,TNCC Trauma Nursing Core Course 15th
Edition ENA Test Bank |Graded A+ pass
ch. 5, p. 42
Explain the B2-Transferrin test - ansGold standard for identifying CSF otorrhea or rhinorrhea
ch. 5, p. 48
Explain the Cushing response - ansLoss of auto regulation (cerebral blood flow) can result in cerebral and
brainstem ischemia, initiating a central nervous system response known as Cushing response. It is
characterized by a triad of assessment findings:
- widening pulse pressure
- reflex bradycardia
- diminished respiratory effort
Ch. 9, p. 107
Explain the LMNOP mnemonic - ansUsed to remember resuscitation adjuncts
L - Lab studies (ABGs, blood type and crossmatch)
- Lactic acid is an excellent reflection of tissue
perfusion
M - Monitor cardiac rate and rhythm: compare patient's pulse to the monitor's rhythm
- Dysrhythmias (PVCs, a fib, or ST segment changes)
may indicate blunt cardiac trauma
- PEA may point to cardiac tamponade, tension
pneumothorax, or profound hypovolemia
N - Naso- or orogastric tube consideration: insertion provides stomach content evacuation and relief of
gastric distention
O - Oxygenation and ventilation assessment
- Pulse ox may only be accurate if there is adequate
peripheral perfusion
- ETCO2 monitoring (capnography) provides instantaneous information about the ventilation, perfusion,
and metabolism of carbon dioxide (35-45 is normal)
ch. 5, p. 47
Explain the MARCH mnemonic - ansM: MASSIVE HEMORRHAGE
A: AIRWAY
R: RESPIRATION - decompress suspected pneumo, seal open chest wounds, support ventilation and
oxygenation as required
C: CIRCULATION - vascular access and admin fluids
H: HEAD INJURY/HYPOTHERMIA - prevent or treat hypotension and hypoxia to prevent worsening of
traumatic brain injury and prevent or treat hypothermia
ch. 5, p. 41-42
Explain TRACHEOBRONCHIAL INJURY and what are the assessment findings and interventions -
ansUsually caused by penetrating mechanisms, occurring in proximal trachea. Direct blows to neck or
clothesline-type injuries common mechanisms for blunt trauma. Dx based on assessment findings and
confirmed with BRONCHOSCOPY or CT.
Assessment findings include:
- DYSPNEA, TACHYPNEA
- HOARSENESS
- SUBCUTANEOUS EMPHYSEMA in neck, face, upper thorax
,TNCC Trauma Nursing Core Course 15th
Edition ENA Test Bank |Graded A+ pass
- PNEUMOTHORAX, tension pneumothorax
- HEMOPTYSIS
- DECREASED OR ABSENT BREATH SOUNDS
- SIGNS and SYMPTOMS of AIRWAY OBSTRUCTION
Interventions include:
- Attempts at ET placement may cause further damage, anesthesiology if available may reduce risk of
intubation injury
- Other approaches include flexible endoscopy, or smaller ET tube
Ch. 11, p. 143
Explain what second impact syndrome is - ansRefers to a condition that occurs when patient suffers a
mild second TBI before recovery from the first. Rare but usually fatal. The second impact causes LOSS OF
AUTO REGULATION LEADING TO CEREBRAL EDEMA
Ch. 9, p. 115
Explain what Tranexamic acid (TXA) is - ansA synthetic version of the amino acid lysine. It is an
antifibrinolytic that inhibits activation of plasminogen, a substance responsible for dissolving clots.
ch. 7, p. 81
Explain why antipyretics are not effective in treating hyperthermia in acute brain injury. - ansFever is
result of a change in thermoregulatory set point. A cooling blanket or ice packs may be used. Avoid
causing shivering, it increases cerebral metabolic rate and may cause ICP to rise
Ch. 9, p. 118
External energy forces can be exerted on the body by the following forces - ans- Deceleration forces:
include those applied in falls and collisions where injuries are caused by sudden stop of the body's motion
- Acceleration forces: not as common as deceleration forces and result from a sudden and rapid onset of
motion (parked car being hit by a vehicle traveling at a high rate of speed)
- Compression force is an external force applied at times of impact, explains include:
+ Stationary objects such as dashboards or steering wheels, that collide with or push up into a person
+ Objects in motion such as bullets and stabbing instruments, bats and balls, fists and feet, or heavy
falling objects
+ Blast forces
p. 27
FLAIL CHEST - ansClassified as 2 or more fractures of 3 or more adjacent ribs and/or sternal fractures,
creating free-floating segment
Assessment findings include
- PARADOXICAL CHEST MOVEMENT drawing in with chest expansion and pushing out with exhalation
- DYSPNEA
- CHEST WALL PAIN, CONTUSIONS
Interventions
- prepare for intubation
Ch. 11, p. 144
, TNCC Trauma Nursing Core Course 15th
Edition ENA Test Bank |Graded A+ pass
Following the primary survey, FAST examination may be used to rapidly assess for bleeding from damage
to the... - ansHeart, liver, kidneys, and spleen. FAST also increasingly used to detect pneumothorax,
especially tension pneumothorax.
ch. 7, p. 84
For skin, the immediate goal in treating surface trauma is to... and this is accomplished by... - ansOBTAIN
AND MAINTAIN HEMOSTASIS, APPLY DIRECT PRESSURE TO SITE
ch. 14, p. 208
HEMOTHORAX - anscaused by blood accumulating in the intrapleural space. Results from injury to lung,
costal blood vessels, great vessels and from laceration to liver or spleen combined with diaphragm injury.
Assessment findings include
- ANXIETY or RESTLESSNESS
- DYSPNEA, TACHYPNEA
- CHEST PAIN
- SIGNS OF SHOCK- tachycardia, cyanosis, diaphoresis, hypotension
- DECREASED BREATH SOUNDS ON INJURED SIDE
Interventions
- Prepare for needle thoracentesis and chest tube insertion
- Ensure 2 large IV catheters and blood is available before thoracentesis to treat large volume blood loss if
needed
ch. 11, p. 146
How can the trauma nurse have an impact when it comes to the legislative process? - ansBy advocating
for stronger laws and more consistent enforcement
p. 11
How can you check for laxity or instability for possible pelvic fractures? - ansgentle pressure over iliac
wings DOWNWARD and MEDIALLY
ch. 12, p. 159
How high should you elevate limb in compartment syndrome? - ansAt level of heart, any higher can reduce
circulation and tissue perfusion. Also ice is strongly contraindicated
ch. 14, p. 200-201
How should you wrap an amputated part? - ansWrap it in slightly saline-moistened sterile gauze, placed in
sealed plastic bag THEN place in a second bag containing ice water
ch. 14, p. 201
hyperEXTENSION - ansetiology/cause- backward thrust beyond anatomic capacity of vertebral column
rest of injury- stretching or ligament tears, bony dislocations
example- rear-end whiplash
Edition ENA Test Bank |Graded A+ pass
Explain pancreatic injuries - ans- Penetrating pancreatic injuries often sustain concurrent duodenal
injuries
- Less than 10% of those with a pancreatic injury will have a single-system injury
- Suspicion for spinal fractures when the pancreas is crushed between anterior abdominal wall and spinal
column
ch. 12, p. 164
Explain pericardial tamponade and its assessment findings - ansWhen there is a rapid accumulation of
blood in pericardial sac, resulting in compression of heart making it difficult for heart to fill during
diastole, causing decreased cardiac output.
Assessment findings include:
- HYPOTENSION
- TACHYCARDIA
- MUFFLED HEART SOUNDS
- NECK VEIN DISTENTION
Ch. 11, p. 141
Explain RETROBULBAR HEMATOMA - ansTRUE OPHTHALMOLOGIC EMERGENCY
Hemorrhage into space behind globe; bleeding causes increased pressure behind globe causing elevation
in IOP that compresses optic nerve and blood vessels. Early recognition is imperative to save vision.
Assessment findings include:
- SEVERE PAIN
- DECREASED VISION
- REDUCED EYE MOVEMENT
- IOP > 40 mm Hg
Treatment include:
- Emergency decompression via LATERAL CANTHOTOMY indicated with IOP > 40 mm Hg
Ch. 10, p. 131
Explain stable and unstable pelvic fractures - ansStable- does not involve pelvic ring or there is minial
displacement of pelvic ring
Unstable fractures- 2 or more fractures of pelvic ring that have outward rotational displacement
ch. 12, p. 166
Explain the AVPU mnemonic - ansUsed to quickly assess patient's level of alertness
A- ALERT
(If any of the responses below are elicited at this point, the airway may be compromised)
V- responds to VERBAL stimuli, airway adjunct may be needed to keep tongue from obstructing airway
P - responds to PAIN.
U- UNRESPONSIVE. If patient is unresponsive, announce loudly to the team and direct someone to check
if the patient has a pulse while assessing if the cause of the problem is the airway. Consider reprioritizing
the assessment priority to <C>ABC
,TNCC Trauma Nursing Core Course 15th
Edition ENA Test Bank |Graded A+ pass
ch. 5, p. 42
Explain the B2-Transferrin test - ansGold standard for identifying CSF otorrhea or rhinorrhea
ch. 5, p. 48
Explain the Cushing response - ansLoss of auto regulation (cerebral blood flow) can result in cerebral and
brainstem ischemia, initiating a central nervous system response known as Cushing response. It is
characterized by a triad of assessment findings:
- widening pulse pressure
- reflex bradycardia
- diminished respiratory effort
Ch. 9, p. 107
Explain the LMNOP mnemonic - ansUsed to remember resuscitation adjuncts
L - Lab studies (ABGs, blood type and crossmatch)
- Lactic acid is an excellent reflection of tissue
perfusion
M - Monitor cardiac rate and rhythm: compare patient's pulse to the monitor's rhythm
- Dysrhythmias (PVCs, a fib, or ST segment changes)
may indicate blunt cardiac trauma
- PEA may point to cardiac tamponade, tension
pneumothorax, or profound hypovolemia
N - Naso- or orogastric tube consideration: insertion provides stomach content evacuation and relief of
gastric distention
O - Oxygenation and ventilation assessment
- Pulse ox may only be accurate if there is adequate
peripheral perfusion
- ETCO2 monitoring (capnography) provides instantaneous information about the ventilation, perfusion,
and metabolism of carbon dioxide (35-45 is normal)
ch. 5, p. 47
Explain the MARCH mnemonic - ansM: MASSIVE HEMORRHAGE
A: AIRWAY
R: RESPIRATION - decompress suspected pneumo, seal open chest wounds, support ventilation and
oxygenation as required
C: CIRCULATION - vascular access and admin fluids
H: HEAD INJURY/HYPOTHERMIA - prevent or treat hypotension and hypoxia to prevent worsening of
traumatic brain injury and prevent or treat hypothermia
ch. 5, p. 41-42
Explain TRACHEOBRONCHIAL INJURY and what are the assessment findings and interventions -
ansUsually caused by penetrating mechanisms, occurring in proximal trachea. Direct blows to neck or
clothesline-type injuries common mechanisms for blunt trauma. Dx based on assessment findings and
confirmed with BRONCHOSCOPY or CT.
Assessment findings include:
- DYSPNEA, TACHYPNEA
- HOARSENESS
- SUBCUTANEOUS EMPHYSEMA in neck, face, upper thorax
,TNCC Trauma Nursing Core Course 15th
Edition ENA Test Bank |Graded A+ pass
- PNEUMOTHORAX, tension pneumothorax
- HEMOPTYSIS
- DECREASED OR ABSENT BREATH SOUNDS
- SIGNS and SYMPTOMS of AIRWAY OBSTRUCTION
Interventions include:
- Attempts at ET placement may cause further damage, anesthesiology if available may reduce risk of
intubation injury
- Other approaches include flexible endoscopy, or smaller ET tube
Ch. 11, p. 143
Explain what second impact syndrome is - ansRefers to a condition that occurs when patient suffers a
mild second TBI before recovery from the first. Rare but usually fatal. The second impact causes LOSS OF
AUTO REGULATION LEADING TO CEREBRAL EDEMA
Ch. 9, p. 115
Explain what Tranexamic acid (TXA) is - ansA synthetic version of the amino acid lysine. It is an
antifibrinolytic that inhibits activation of plasminogen, a substance responsible for dissolving clots.
ch. 7, p. 81
Explain why antipyretics are not effective in treating hyperthermia in acute brain injury. - ansFever is
result of a change in thermoregulatory set point. A cooling blanket or ice packs may be used. Avoid
causing shivering, it increases cerebral metabolic rate and may cause ICP to rise
Ch. 9, p. 118
External energy forces can be exerted on the body by the following forces - ans- Deceleration forces:
include those applied in falls and collisions where injuries are caused by sudden stop of the body's motion
- Acceleration forces: not as common as deceleration forces and result from a sudden and rapid onset of
motion (parked car being hit by a vehicle traveling at a high rate of speed)
- Compression force is an external force applied at times of impact, explains include:
+ Stationary objects such as dashboards or steering wheels, that collide with or push up into a person
+ Objects in motion such as bullets and stabbing instruments, bats and balls, fists and feet, or heavy
falling objects
+ Blast forces
p. 27
FLAIL CHEST - ansClassified as 2 or more fractures of 3 or more adjacent ribs and/or sternal fractures,
creating free-floating segment
Assessment findings include
- PARADOXICAL CHEST MOVEMENT drawing in with chest expansion and pushing out with exhalation
- DYSPNEA
- CHEST WALL PAIN, CONTUSIONS
Interventions
- prepare for intubation
Ch. 11, p. 144
, TNCC Trauma Nursing Core Course 15th
Edition ENA Test Bank |Graded A+ pass
Following the primary survey, FAST examination may be used to rapidly assess for bleeding from damage
to the... - ansHeart, liver, kidneys, and spleen. FAST also increasingly used to detect pneumothorax,
especially tension pneumothorax.
ch. 7, p. 84
For skin, the immediate goal in treating surface trauma is to... and this is accomplished by... - ansOBTAIN
AND MAINTAIN HEMOSTASIS, APPLY DIRECT PRESSURE TO SITE
ch. 14, p. 208
HEMOTHORAX - anscaused by blood accumulating in the intrapleural space. Results from injury to lung,
costal blood vessels, great vessels and from laceration to liver or spleen combined with diaphragm injury.
Assessment findings include
- ANXIETY or RESTLESSNESS
- DYSPNEA, TACHYPNEA
- CHEST PAIN
- SIGNS OF SHOCK- tachycardia, cyanosis, diaphoresis, hypotension
- DECREASED BREATH SOUNDS ON INJURED SIDE
Interventions
- Prepare for needle thoracentesis and chest tube insertion
- Ensure 2 large IV catheters and blood is available before thoracentesis to treat large volume blood loss if
needed
ch. 11, p. 146
How can the trauma nurse have an impact when it comes to the legislative process? - ansBy advocating
for stronger laws and more consistent enforcement
p. 11
How can you check for laxity or instability for possible pelvic fractures? - ansgentle pressure over iliac
wings DOWNWARD and MEDIALLY
ch. 12, p. 159
How high should you elevate limb in compartment syndrome? - ansAt level of heart, any higher can reduce
circulation and tissue perfusion. Also ice is strongly contraindicated
ch. 14, p. 200-201
How should you wrap an amputated part? - ansWrap it in slightly saline-moistened sterile gauze, placed in
sealed plastic bag THEN place in a second bag containing ice water
ch. 14, p. 201
hyperEXTENSION - ansetiology/cause- backward thrust beyond anatomic capacity of vertebral column
rest of injury- stretching or ligament tears, bony dislocations
example- rear-end whiplash
