TNCC 9th edi.
A patient with a traumatic brain injury has a mean arterial pressure (MAP) of 65 mm Hg (8.66 kPa) and an intracranial pressure (ICP) of 22 mm Hg (2.93 kPa). Which finding is most likely an indication of the body's response to these findings?
reflex tachycardia
Which blood pressure finding is associated with early or compensated hypovolemic shock?
rising diastolic
A restrained driver involved in a motor vehicle collision is brought to the emergency department with abdominal, pelvic, and bilateral lower extremity pain. Vital signs are BP 114/78 mm Hg, HR 98 beats/minute, RR 22 breaths/minute. A FAST exam is negative for fluid in the abdominal and peritoneal cavities. Which of the following should the nurse anticipate?
serial abdominal assessments
What assessment finding is consistent with impending herniation syndrome?
unilaterally fixed and dilated pupil
A patient has been diagnosed with an incomplete spinal cord injury at L1. Which finding would indicate sacral sparing?
voluntary anal sphincter tone
Which of the following is a late sign of increased intracranial pressure?
widening pulse pressure, reflex bradycardia, decreased respiratory effort
Based on full mechanism, which patient warrants prehospital transfer to a trauma center?
2-year-old falling from second story onto grass
A patient has received multiple transfusions of banks blood in the past two hours. the patient has
Calcium gluconate
What position optimizes ventilation in the obese patient with a lumbar fracture?
Reverse trendelenburg
A patient arrives at the emergency department following a motor vehicle collision. Prehospital personnel report significant damage to the vehicle. The patient is alert and agitated with a strong odor of alcohol and appears intoxicated. After physician evaluation, under what circumstance can an order to remove the rigid cervical collar be anticipated?
no imaging abnormalities of the neck
You are caring for a patient who was thrown from a bike and was not wearing a helmet. While performing the head-to-toe assessment, you note clear drainage from the right ear. Which of the following is the most appropriate next step?
notify the provider
An adult patient is brought to the emergency department following a vehicle "roll-over" with prolonged extrication. Assessment reveals swelling and bruising to the right proximal thigh and a weak pedal pulse. Skin is pale, cool, and moist. What is the most appropriate initial intervention?
paradoxical chest movement
An adult patient involved in an assault presents with shortness of breath, BP 88/50 mmHg, heart rate of 130 beats/minute, and RR 32 breaths/minute. The patient has muffled heart sounds and is cyanotic. What is the priority intervention?
pericardiocentesis
An older adult presents to the emergency department with complaints of dizziness, headache, and nausea. The patient was involved in a motor vehicle collision 10 days ago. There was no loss of consciousness, and a hematoma is noted to the forehead. The patient is currently on anticoagulant therapy. What is most likely the cause of their symptoms?
post-concussive syndrome??
What intravascular solution is most commonly use for patients who have sustained burns?
Lactated Ringers (LR)
Following a gun shot wound, pre-hospital providers report diminished breath sounds bilaterally. Upon emergency department arrival, the patient is unresponsive with shallow respirations and an O2 sat of 88%. What is the priority intervention for this patient?
Pneumothorax, hemothoax, contusion, or flail chest
A patient who weighs 120 kg is brought to the emergency department after sustaining partial thickness burns to both upper extremities and chest with a total body surface area burned of 27%. How much intravenous fluid should be administered in the first 8 hours?
3240 mL - unsure
A patient has uncontrolled bleeding from a wound to his right upper extremity. What is a priority intervention?
Apply direct pressure to the wound
A 36-year-old patient has a deformity of the left wrist after a fall. The patient is reluctant to move her hand due to pain. Which of the following is the most appropriate intervention?
Apply splint and elevate above the level of the heart
A patient with a complete spinal cord injury, who is a neurogenic shock will demonstrate hypotension and which other clinical signs?
Bradycardia and absent motor function below the level of injury
A trauma patient is being held in the emergency department, because there are no available inpatient beds. The patient has seen a femur fracture and required multiple blood products. The patient now has blood oozing from abrasions, IV sides, the nose, and gums. What condition is most consistent with these findings?
DIC
A patient arrives with a large open chest wound after being assaulted with a machete. Prehospital professionals placed a non-porous stressing over the Chesswood and taped it on three sides. He is now showing signs of anxiety, restlessness, severe respiratory distress, cyanosis, and decrease in blood pressure. Which of the following is the most appropriate immediate intervention?
Dressing removal
A patient with a lower extremity fracture, complains of severe pain and tightness in his calf, minimally by pain medication's. Which of the following is a priority, nursing intervention?
Elevating the extremity to the level of the heart
What is the rationale for obtaining a serum lactate level during the initial assessment of a trauma patient
Gauges end-organ perfusion and tissue hypoxia
A 35-year-old male presents with facial trauma after being struck in the face with a baseball. A teardrop shaped left people is noted on exam. What type of injury is suspected?
Globe rupture
A patient is brought to the emergency department of a rural hospital following a high-speed motor vehicle collision. When significant abdominal and pelvic injuries are noted in the primary survey, which of the following is a priority intervention?
Initiate transfer to trauma center
A patient is thrown against a car during a tornado in presents with obvious bilateral femur fractures. The patient is pale, alert, disoriented, and has delayed capillary refill. Which of the following interventions would be most appropriate for this patient based on the disaster triage principles?
Initiate two large caliber IVs for LR administration
During the primary survey of an unconscious, patient with multisystem trauma, the nurse notes snoring, respirations. What priority nursing intervention should be performed next?
Insert in oropharyngeal airway, if there is no gag reflex
Which of the following is true about use of the focused assessment sonography for trauma exam for a patient with abdominal trauma?
It can be used in hypotensive patients too unstable for computed tomographic scan."
Your patient is a pedestrian struck by a car and thrown 35 feet. They were unconscious at the scene but became responsive with initial and subsequent Glasgow Coma Scale (GCS) scores of 13 (E-3, V-4, M-6). The patient has bilateral subdural hematomas and is awaiting transfer to the ICU. Your next assessment reveals a GCS of 9 (E-2, V-2, M-5). What is the priority nursing intervention?
Notify the provider of the change
You are caring for a patient who was involved in a motor vehicle crash and is 32 weeks pregnant. Findings of your secondary survey include abdominal pain with rigidity on palpation, fundal height at the costal margin, and dark bloody vaginal discharge. Varying accelerations and decelerations are noted on cardiotocography. These findings are most consistent with which of the following?
Placental abruption
An adult patient with a restraint passenger involved in a high-speed motor vehicle collision. The patient complained of generalized abdominal and left leg pain. A fast examines negative for fluid in the abdominal cavity. While awaiting impatient bed placement, the patient develops increase abdominal pain with rebound tenderness, fever, in an elevated white blood cell count. These findings are most consistent with an injury to which organ?
Small bowel
You are speaking with the family of a critically injured patient. The spouse is crying loudly and the daughter is angry and yelling at the staff. Which of the following nursing interventions is most appropriate?
Spiritual support
An adult who fell from a second story roof is brought to the emergency department by private vehicle. The patient is confused with an labored, respirations. It has strong, palpable, radial pulses. There is an open wound in proximity to Novios, deformity of the left lower extremity. What is the priority intervention?
Stabilize the C-spine
An older patient with a history of anticoagulant use presents after a fall at home the previous day. She denies LLC. She has a hematoma to her for head and complains of headache, dizziness, and nausea. What is the most likely cause of her symptoms?
Subdural hematoma
A teenaged patient presents to the emergency department with left arm pain after a ground level fall. The patient identifies as transgender and shares they are homeless. The ED staff are concerned the patient is experiencing human trafficking. What is most consistent with human trafficking?
Those experiencing human trafficking rarely self-disclose.
When can an accurate determination of total body surface area burned be made in order to make a definitive calculation for intravenous fluid resuscitation?
after removal of clothing
A patient who jumped out of a second-floor window, landing on their feet is diagnosed with a lumbar spinal fracture. What is the most likely concurrent injury to have occurred?
calcaneus fracture
A trauma patient is restless and repeatedly asking "where am I?" Vitals upon arrival were BP 110/60, HR 96, RR 24. Her skin is cool and dry. Current vital signs are BP 104/84, heart rate 108, respirations 28. The patient is demonstrating signs and symptoms of which stage of shock.
compensated
A patient with a chest tube is being transported to the intensive care unit and fluctuation is noted in the water seal chamber during inspiration and expiration. What is the best action for the nurse to take?
continue to ICU
An unconscious patient arrives following a motor vehicle collision. The patient is on a backboard with a cervical collar in place and one intravenous line running. Respirations are shallow and there is active brisk bleeding from a large leg wound. What is the priority intervention for this patient?
control the bleeding
An adult patient who sustained a severe head trauma has been intubated and has been manually ventilated via a bag mask device at a rate of 18 breaths per minute. The patient has received one intravenous fluid bolus of 500 ML of warmed isotonic crystalloid solution. The PaCO2 is 30 and a pulse ox symmetry is 92%. BP is 142/70. What is the most important intervention to manage the cerebral blood flow?
decrease the rate of manual ventilation
Patients with a crush injury should be monitored for which of the following conditions?
dysrhythmias
A nurse, verbalizes, guilt and remorse after caring for multiple severely injured patience during a staffing crisis. The nurse expresses anger stating that the patient did not receive quality care and begins exhibiting aggression towards colleagues. This is most consistent with which condition?
emotional
Which of the following is true regarding cavitation?
energy causes the tissues to accelerate and displace outward
A patient is diagnosed with a T 12 spinal cord injury, following a 12 foot for which finding is consistent with spinal shock?
flaccidity, loss of bowel and bladder
Following a motor vehicle collision, a patient presents with decreased level of consciousness and respirations that are intermittently accompanied by snoring. It has been determined that it is safe to insert a nasopharyngeal airway. What is most important to consider when preparing to insert the nasopharyngeal airway?
gastric distention
Three adults present at different times during a one-hour period with a high fever, fatigue, and headache. All three patients have a rash which started on their mouth, face, and arms with progression to the chest and abdomen. They all visited the same grocery store within the last week. What is the most appropriate intervention from triage for these patients?
immediately initiate isolation precautions
A trauma patient who is 30 weeks pregnant arrives at the emergency department following a motor vehicle crash
increased oxygen consumption
What is the most important consideration during the initial assessment when caring for an older adult who has sustained serious injuries?
medical history including current medications
