TNCC Exam 8th edition study

Which of the following is a late sign of increased intracranial pressure?

Decreased respiratory effort Other late signs of increased intracranial pressure include dilated, nonreactive pupils, unresponsiveness, abnormal motor posturing, and the Cushing response.

What physiologic change in the elderly population increases the risk of traumatic injury?

Decreased subcutaneous fat Decreased subcutaneous fat and thinning of the skin increases the risk of injuries from soft tissue trauma and increases the risk of hypothermia

All of these are considered a critical communication point in trauma care EXCEPT which of the following?

Defusings A defusing is part of critical incident stress management but is not considered a critical communication point in trauma care.

A toddler who fell off a trampoline is making eye contact with the family and is consolable. There is no increased work of breathing and the skin color is pink. The nurse asks the patient to open his mouth, but the patient does not respond to commands. The nurse recognizes this as an expected finding due to which of the following conditions?

Developmental stage An alert or older infant or toddler will recognize his or her caregiver but be cautious of strangers and my not respond to commands This is normal.

Which of the following is NOT considered a benefit of debriefings?

Identifying individuals who made mistakes during the traumatic event Debriefings are not used to single out individuals who made mistakes. Debriefings are used to provide an opportunity to review performance and identify areas for improvement with a sharing of individual responses.

.During the primary survey of an unconscious patient with multi-system trauma, the nurse notes snoring respirations. What priority nursing intervention should be performed next?

Insert an oropharyngeal airway if there is no gag reflex Snoring respirations may indicate airway obstruction from the tongue. Insert an airway adjunct to alleviate obstruction by the tongue. Oropharyngeal airways can be used in patients without a gag reflex.

An intubated and sedated patient in the emergency department has multiple extremity injuries with the potential for causing compartment syndrome. What is the most reliable indication of compartment syndrome in a patient who is unconscious?

Pressure Pressure can be assessed in the limb by palpation or direct measurement. The compartment or limb will feel tight or tense upon palpation. The skin may also appear taut and shiny.

When is the tertiary survey completed for a trauma patient?

Within 24 hours of the trauma The tertiary survey consists of a complete examination performed following the primary and secondary surveys and within 24 hours after trauma to identify any injuries missed during the initial assessment.

Which of the following is most likely to contribute to inadequate oxygenation and ventilation?

Advanced age Older patients are more likely to have pulmonary comorbidities and decreased pulmonary reserve.

There has been a mass casualty incident a block from the hospital. The hospital is receiving dozens of patients. A truck arrives with an unresponsive patient in the back with obvious chest and abdominal trauma. Agonal respirations do not improve with airway positioning. Using the START triage algorithm, you would triage tag this patient as which of the following?

Black This patient is unlikely to survive given the severity of their injuries and is triaged as expectant. Resources should be reserved for individuals considered to be more salvageable.

A patient with a lower extremity fracture complains of severe pain and tightness in his calf, minimally relieved by pain medications. Which of the following is the priority nursing intervention?

Elevating the extremity to the level of the heart Elevating the extremity higher than the heart can reduce circulation and tissue perfusion if compartment syndrome is suspected.

The nurse is assessing a patient with a fractured forearm that was splinted three hours ago. Which symptom is of most concern as a late sign of an evolving complication?

Weak radial pulse A weak radial pulse is evidence of an actual compromise in circulation.