TNCC TRAUMA NURSING CORE
COURSE 11TH EDITION ENA TEST
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1. Which of the following requires you to develop a plan of action, initiate the plan,
reassess the plan as care for the patient moves forward, and adjust the plan as the
patient's condition or circumstances change?
A. Principles of PHTLS
B. The Golden Period
C. The XABCDE assessment
D. Critical thinking process - ansQuestion 1: D
To help achieve the PHTLS goals, you will apply your critical thinking skills in the field.
Critical thinking in medicine is a process in which the healthcare practitioner assesses
the situation, the patient, and the resources available and uses the information to decide
on and provide the best care for the patient.
1. You and your partner are responding to a call for a 2-year-old patient with a burn
injury to the hand. He has a visible burn to the left hand, ending at the level above the
wrist, red color, and wet in appearance. What type of burn do you suspect the patient
has sustained?
A. Superficial (first degree)
B. Partial thickness (second degree)
C. Full thickness (third degree)
D. Subdermal (fourth degree) - ansQuestion 1: B
Scald burns are the most common burns seen in the pediatric population ages 1 to 5
years. Scalds are partial thickness burns. The dermal layer is damaged, and blisters are
present or popped. It is also the most painful type of burn.
1. You are called to the scene of a possible mass casualty motor vehicle collision on the
highway. Once you arrive on scene, what is your first priority?
A. Immediately begin triaging patients.
B. Treat the patient with the most visible blood loss.
C. Determine the need for additional resources.
D. Assess the scene and ensure it is safe. - ansQuestion 1: D
Ensure safety for responders, bystanders, and patient(s). The first consideration when
approaching any scene is the safety of all emergency responders. When EMS
personnel become victims, they not only can no longer assist others, but also add to the
number of patients.
1. You are called to the scene of an explosion and fire at a chemical plant where you
find multiple casualties.Triage has begun. Your first patient is a 40-year-old man who
was near the source of the explosion. He is unconscious and has extensive injuries.

TNCC TRAUMA NURSING CORE
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You note gurgling respirations. Why should you use the trauma jaw thrust maneuver
first when dealing with a trauma patient?
A. It's an easy technique that always works to open the airway.
B. It allows you to open the airway with little or no movement of the head and cervical
spine.
C. Other techniques and interventions don't work as well.
D. It can relieve a variety of anatomic airway obstructions in patients who are breathing
spontaneously. - ansQuestion 1: B
Manual maneuvers like the trauma jaw thrust or chin lift are always the first airway
maneuver you should make when treating a trauma patient. In patients with suspected
head, neck, orfacial trauma, the cervical spine is maintained in a neutral in-line
position.The trauma jaw thrust maneuver allows you to open the airway with little or no
movement of the head and cervical spine.
1. You are responding to a call for 25-year-old, fit and healthy female who fell off a
mountain bike. Upon arrival, you find the patient walking around. She is alert but
complaining of pain in her clavicle and on her right side when she inhales. You notice
that her helmet is split in two. What is the first thing you need to do?
A. Complete a review of the ABCs.
B. Check motor and sensory function.
C. Perform manual in-line stabilization.
D. Place her on a backboard. - ansQuestion 1: C
Because there's a possibility of spinal injury, you should bring the patient's head into a
neutral in-line position.
1. You have been performing ongoing management on a 35-year-old female patient
who sustained thoracic trauma when a car hit her as she crossed the street. Originally,
your electronic monitoring devices all produce results consistent with your patient's
clinical condition. However, en route the trauma center, the monitors start to differ from
your patient's current clinical condition each time you reassess. How should you handle
this situation?
A. Treat the patient's condition, not the monitor results.
B. Continue to reassess the patient and record the results for the trauma center.
C. Treat your patient based on the test results.
D. Stop testing and wait until you arrive at the trauma center for them to perform an
assessment. - ansQuestion 1: A
If there are inconsistent data from electronic monitoring devices, reassess to be sure
the monitor matches the patient's current clinical condition. However, it is most
important to treat the patient, not the monitor, so use other signs and symptoms of
potential patient deterioration.

TNCC TRAUMA NURSING CORE
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1. You're called out to an assisted living facility for a 72-year-old woman complaining of
a severe headache and experiencing increased confusion. Staff reports she fell out of
her wheelchair earlier in the week but didn't appear to be hurt; however, she's become
increasingly disoriented over the last day or so. Vital signs show: BP 110/90; heartrate
118 and irregularly regular; ventilation rate 20 and slightly labored; SpO2 93% on room
air. She is taking warfarin for a clotting issue. Which of the following should you
suspect?
A. Cerebral contusion
B. Epidural hematoma
C. Subarachnoid hemorrhage
D. Subdural hematoma - ansQuestion 1: D
The patient's age, use of a blood thinner, and the fact she fell recently point to a
subdural hematoma.
1. Your partner is compressing the bleeding site of a male patient who was stabbed
multiple times in the left chest. The bleeding seems to be controlled, yet the patient
becomes combative. He is pale and is breathing rapidly, yet states that he "can't
breathe" and feels that he is about to die. Your next step in patient management is to:
A. start assisted ventilation.
B. give high-flow oxygen.
C. decompress the left chest.
D. give a 250-mL fluid bolus. - ansQuestion 1: C
After X come A and B. You can quickly auscultate the lungs (pneumothorax is almost
certain with multiple stabs in the chest) and decompress the chest. Decompressing a
tension pneumothorax is the quickest way to treat shock.
1. Your patient is experiencing severe pain after sustaining a femur fracture in a
motorcycle crash. You have a 20 minute transport to the nearest trauma center. There
are no other injuries noted on your primary and secondary assessments. Which of the
following medications would be the best pain management choice?
A. NSAIDs
B. Acetaminophen
C. Fentanyl
D. Morphine - ansQuestion 1: C
Fentanyl is often a first-line agent due to speed of onset, short duration of action, and
minimal effect on hemodynamics. Fentanyl can beadministered IN, IM, IO, or IV. The IV
route provides effects instantly whereasthe IN and IM route have an onset of <10
minutes. The duration of fentanyl is short at 30 minutes to an hour. This will provide
enough time to ease pain during transport and let the traumacenter decide pain
management upon arrival.

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TNCC TRAUMA NURSING CORE
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2. A trauma patient from the highway incident is holding her right arm, and you note a
significant amount of blood steadily flowing from a long gash. This is an example of
what type of hemorrhage?
A. Capillary bleeding
B. Venous bleeding
C. Arterial bleeding
D. Road rash - ansQuestion 2: B
Venous bleeding typically results in a steady flow of dark red blood.
2. During primary survey, you find the following:
. LOC: alert and oriented; speaking in full sentences
. GCS: 15
. Airway: good air entry to bases
. Breathing: bilateral
. Circulation: skin warm, flushed, dry
. Pulse rate: 112 bpm, strong andregular
. BP: 90/42 mm Hg
. Pain: Patient complains of severe pain at clavicle site and pain on inspiration at site of
possible fractured ribs. No other injuries detected. What is your next step?
A. Apply a cervical collar and in-line immobilization device.
B. Treat for hypovolemic shock.
C. Apply an arm sling for the clavicle injury.
D. Administer pain medication. - ansQuestion 2: A
Although the patient's GCS is normal, she does have a distracting injury, and the state
of her helmet indicates possible spinal compression/flexion, so you should immobilize
the patient.
2. The patient becomes apneic. You suspect he has a cervical injury. Which type of
airway should you use?
A. Supraglottic airway
B. Blind nasotracheal intubation
C. Oropharyngeal airway
D. Surgical airway - ansQuestion 2: A
The supraglottic airway's greatest advantage is that it can be inserted independent of
the patient's position, which may be especially important in trauma patients with high
suspicion of cervical injury.
2. The patient's care giver is a babysitter who reports the child was crawling on the
counter and placed his hand in a pot of water that was boiling on the stove. She is
applying ice to the burn and the child is shivering. What is your next step?
A. Administer analgesia for pain.
B. Cover the patient with a blanket to stop the shivering.

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TNCC TRAUMA NURSING CORE
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C. Start IV for fluid resuscitation.
D. Stop the burning process and remove the ice pack. - ansQuestion 2: D
A common error that results in damage to the zone of stasis is the application of ice by
a bystander or prehospital care practitioner. When ice is applied to a burn, the patient
will experience some reduction in pain; however, the pain relief will be at the expense of
additional tissue destruction.
2. The patient's respiration improves markedly, but he remains confused. He has an
absent radial pulse, and his carotid pulse is fast and thready. Your partner asks if he
can let the compression go to put in an IV. How should you respond?
A. "Oh yes, that's a great idea!"
B. "Yes, but we have to immobilize him first"
C. "Take a blood pressure first to see if he needs an IV."
D. "No, keep the pressure and let's get out of here!" - ansQuestion 2: D
This patient is likely in decompensated shock with internal bleeding, so rapid transport
is the next priority. You should maintain pressure on the wound, because having
massive external bleeding start up again is the last thing you want in this situation.
2. Upon examination, you find the patient responsive to your presence, although she is
clearly confused. Motor response shows reduced pain response but normal flexion.
What's her GCS score?
A. 15
B. 12
C. 10
D. 8 - ansQuestion 2: B
Eye opening: 4; verbal response: 4; motor response: 4 = 12
2. When using the XABCDE assessment, which of the following takes precedence over
all other actions?
A. Controlling severe bleeding from a limb or other compressible site
B. Airway stabilization and assessing circulatory status
C. Exposing the body to allow a thorough evaluation
D. Ensuring adequate breathing - ansQuestion 2: A
The "X" placed before "ABCDE" in the primary survey refers to the need to address
exsanguinating hemorrhage immediately after establishing scene safety and before
addressing airway. Severe exsanguinating hemorrhage, particularly arterial bleeding,
has the potential to lead to loss of total or near total blood volume in a relatively short
period of time.
2. You are responding to a call to an MVC involving one patient. When you perform your
primary survey, you find a patent airway, but abnormalities with breathing and

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TNCC TRAUMA NURSING CORE
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circulation. You suspect hypovolemic shock, but cannot determine the source. What
does this finding most likely indicate?
A. Hemothorax
B. Intra-abdominal bleed
C. Blunt cardiac injury
D. Diaphragmatic rupture - ansQuestion 2: B
The most reliable indicator of an intraabdominal bleed is the presence of hypovolemic
shock from an unexplained source.
2. You have determined that you are going to need to perform orotracheal intubation on
a 50-year-old male motor vehicle crash (MVC) critically injured trauma patient due to
prolonged transport time. What do you need to do first?
A. Preoxygenate to maximize oxygen saturation.
B. Place the patient in a "sniffing"position.
C. Clear the mouth of any obstructions.
D. Prepare the patient for immediate transport. - ansQuestion 2: A
Before insertion of any invasive airway, the patient is preoxygenated with a high
concentration of oxygen using a simple airway adjunct or manual airway procedure.
3. After exposing the patient, no other burn injuries were found, but blisters have started
to form on the hand and the child is crying from pain. How should you manage the
blisters?
A. Lance the blisters to drain the fluidand relieve the pressure.
B. Cover the injury with a dry, loose, sterile dressing, being sure to leave the blisters
intact.
C. Use a topical antibiotic ointment and firmly wrap the burn injury.
D. Establish an IV for fluid resuscitation. - ansQuestion 3: B
In the prehospital setting, blisters are generally best left alone during the relatively short
transport time. Blisters that have already ruptured should be covered with a clean, dry
dressing.
3. What does the GCS score indicate?
A. Mild TBI
B. Moderate TBI
C. Severe TBI
D. No TBI - ansQuestion 3: B
A total GCS score of 13 to 15 likely indicates a mild TBI whereas a score of 9 to 12 is
indicative of moderate TBI. A GCS score of 3 to 8 suggests severe TBI.
3. What is the best way to control the bleeding?
A. Direct pressure
B. Elevation of the arm above the heart

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TNCC TRAUMA NURSING CORE
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C. Tourniquet
D. Occlusive dressing - ansQuestion 3: A
With venous bleeds, direct pressure isusually sufficient to stop the flow.
3. When securing a patient to a backboard, which body part should you secure first?
A. Head
B. Torso
C. Legs
D. Pelvis - ansQuestion 3: B
When immobilizing a patient, you should secure the torso first, then the head, the legs,
and the pelvis.
3. Which of the following is the basis on which a patient's chance of survival is
maximized?
A. Preferences
B. Phases
C. Principles
D. Transport - ansQuestion 3: C
The science of medicine provides the principles of medical care. Simply stated,
principles define the duties required of the prehospital care practitioner in optimizing
patient survival and outcome.
3. While en route to the hospital, you manage to put an 18-gauge IV in the right arm.
Your patient is still confused, and you still have no radial pulse. Your next move is to:
A. give 1-L fluid bolus.
B. give one 250-mL fluid bolus, and then stop.
C. give fluid until you get a radial pulse.
D. administer TXA. - ansQuestion 3: C
Now is the time to titrate IV fluids to restore tissue perfusion. Giving 1 liter blindly could
overshoot your target pressure and reinforce internal bleeding. TXA is not a priority,
although it can run parallel to fluids.
3. Why might it be more difficult to deal with an airway obstruction in a child?
A. Children have longer tracheas.
B. Children have larger heads and tongues so there is a greater potential for airway
obstruction.
C. Children have smaller heads, so there is less room to clear the obstruction.
D. A child's epiglottis is smaller and stiffer than an adult's. - ansQuestion 3: B
Children have larger heads and tongues as compared to an adult so there is a greater
potential for airway obstruction in a pediatric patient. You must pay special attention to
the proper positioning of a pediatric patient to maintain a patent airway.

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TNCC TRAUMA NURSING CORE
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3. You are oxygenating a pediatric patient using a properly fitted oxygen mask and the
"squeeze-release-release" timing technique. As you watch for the rise and fall of the
chest, you check end-tidal CO2 (ETCO2) monitoring aiming to maintain what level?
A. Between 40 and 45 mm Hg
B. Between 30 and 35 mm Hg
C. Between 35 and 40 mm Hg
D. The level is irrelevant because capnography is inaccurate in pediatric patients. -
ansQuestion 3: C
The proper level to maintain is between 35 and 40 mm Hg.
3. You are transporting a 37-year-old male patient with a suspected intraabdominal
bleed. His blood pressure is 70/50 mm Hg (MAP 57), and his skin is pale and
diaphoretic. How will you manage fluid resuscitation for this patient?
A. Aggressively administer IV fluids to compensate for internal blood loss.
B. Do not administer IV fluids to patients with intra-abdominal bleeding.
C. Obtain the patient's medical records and resuscitate to his normal blood pressure
reading.
D. Carefully administer IV fluids to raise the patient's systolic blood pressure to between
80 and 90 mm Hg. - ansQuestion 3: D
Abdominal trauma represents one of the key situations in which a balanced
resuscitation is indicated. Aggressive administration of IV fluid may elevate the patient's
blood pressure to levels that will disrupt any clot that has formed and result in
recurrence of bleeding that had ceased because of blood clotting and hypotension.
Prehospital care practitioners must achieve a delicate balance: maintain a blood
pressure that provides perfusion to vital organs without restoring blood pressure to
elevated or even normal ranges, which may reinitiate bleeding sites in the abdomen or
pelvis. In the absence of TBI, the target systolic blood pressure is 80 to 90 mm Hg
(mean arterial pressure of 60 to 65 mmHg).
4. After 400 mL of lactated Ringer solution, you get a radial pulse and his level of
consciousness improves. The monitor shows heart rate 110 beats/minute, blood
pressure 85/60mm Hg, SpO2 95%, ventilation rate 25 breaths/minute. What should you
do?
A. Give an additional 500 mL of lactated Ringer solution.
B. Stop fluids and give 2 g of TXA.
C. Give TXA and 500 mL of normal saline.
D. Give 2 mg of morphine for analgesia. - ansQuestion 4: B
The patient does not need more fluids right now. Giving morphine in a shocked patient
is a risky move and could lead to dangerous hypotension.

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TNCC TRAUMA NURSING CORE
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4. The patient is wearing long sleeves, and you are having trouble visualizing the
wound. What should you do?
A. Cut the cloth away from the site until the entire wound site is visible.
B. Leave the clothing in place. Put gauze over the wound.
C. Remove the patient's shirt.
D. Cut through the slash on the sleeve, and use the material as a makeshift tourniquet. -
ansQuestion 4: A
Clothing can be quickly removed by cutting. You cannot treat what you cannot see.
4. What is one reason to use capnography as part of your patient reassessment?
A. To get accurate readings for blood pressure
B. To assure proper ET tube placement
C. To measure arterial blood saturation
D. To ensure proper placement for needle decompression - ansQuestion 4: B
Capnography can monitor proper endotracheal tube placement. It doesn't read blood
pressure, so it cannot beused to determine if a patient is hypotensive. Pulse oximetry,
not capnography, measures arterial blood saturation. Capnography is not useful in
needle decompression.
4. What type of padding should you provide for this patient?
A. Use compressible padding under the shoulders and torso to prevent hyperflexion.
B. Use firm padding between the back of the head and the backboard to prevent
hyperextension.
C. Do not use any padding. It can cause extension or flexion in the neck.
D. No padding needed, but to avoid decreased venous return you should tip the
backboard to a left lateral position. - ansQuestion 4: B
Because the patient is an adult, you should use firm padding between the back of the
head and the backboard to prevent hyperextension. You would pad a child's shoulder
and torso to prevent hyperflexion, and you would tip the backboard for a pregnant
patient to prevent decreased venous return.
4. When you examine the patient's pupils, you notice the right one is dilated significantly
and her motor response on the left is delayed. What does this suggest?
A. Coup-countercoup injury
B. Hyphema
C. Hypoxia
D. Uncal herniation - ansQuestion 4: D
When the medial portion of the temporal lobe (uncus) is pushed toward the tentorium
and puts pressure on the brain stem, herniation compresses CN III, the motor tract, and
the reticular activating system on the same side, resulting in a dilated or blown pupil on
the same side, motor weakness on the opposite side, and respiratory dysfunction,
progressing to coma.

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TNCC TRAUMA NURSING CORE
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4. Which of the following is a goal of the Golden Period?
A. Provide written documentation from field care to receiving hospital.
B. Expedite the field care and transport of the patient.
C. Use a team approach for optimal patient care.
D. Use the XABCDE approach to patient assessment. - ansQuestion 4: B
One of your most importantresponsibilities as a prehospital carepractitioner is to spend
as little time onthe scene as possible and expedite yourfield care and transport of the
patient.Studies show that the time from injuryto arrival at the appropriate site
fordefinitive care is critical to survival.
4. Why might you consider early mechanical ventilation via bag-mask device in a
geriatric patient?
A. Shorter tracheas in geriatric patients create the need for ventilation assistance.
B. Laxity of the rib cage makes hyperventilation more likely.
C. Geriatric patients have greatly limited physiologic reserve.
D. Geriatric patients have a greater alveolar surface area of the lungs. - ansQuestion 4:
C
Early mechanical ventilation via bag mask device or advanced airway measures should
be considered in geriatric trauma patients because of their greatly limited physiologic
reserve.
5. Which of the following signs would be most concerning at this point?
A. A drop in systolic blood pressure to 88 mm Hg
B. SpO₂ of 93%
C. A field GCS motor score of 4
D. Hemiplegia on the left side - ansQuestion 5: A
A systolic blood pressure of less than 90 mm Hg indicates secondary brain injury. Her
SpO2 is > 90%, and a motor score of 4 is not as concerning.
5. While attempting to lay the patient supine for spinal motion restriction she becomes
increasingly distressed and complains of shortness of breath and difficulty breathing.
The fractured clavicle appears to move distally and increases the difficulty of breathing
as the patient lies back. What should you do?
A. Tip the backboard to a left lateral position.
B. Raise the back of the stretcher.
C. Let her sit up in a position of comfort.
D. Administer morphine. - ansQuestion 5: B
Because laying the patient supine increases the risk of airway/ventilation problems,
raising the back of the stretchers slightly fundamentally maintains spinal alignment while
reducing the ventilation issues.

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TNCC TRAUMA NURSING CORE
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5. You now perform a secondary survey. You notice a sternotomy scar. Your patient
tells you he is on oral clopidogrel since he had a coronary artery bypass graft 2 years
ago. Is this information useful?
A. No, he should stop talking and breathe.
B. Yes, he should see a cardiologist once in the local hospital.
C. Yes, he will need platelets and a heart surgeon ASAP.
D. Yes, you should raise his blood pressure up to 130 mm Hg systolic. - ansQuestion 5:
C
Because he is on clopidogrel, his platelets are out of order for at least 5 days, so he will
require urgent platelet transfusion.
6. According to the Monro-Kellie doctrine, what happens to the brain when it is still in a
compensated state after a TBI?
A. CSF, ICP, heart rate, and blood pressure are still within normal range.
B. CSF increases, ICP decreases, heart rate increases, and blood pressure decreases.
C. CSF and blood volume decrease, while heart rate and blood pressure are still within
normál range.
D. CSF decreases, ICP increases, heart rate decreases, and blood pressure increases.
- ansQuestion 6: C
In a compensated state, CSF and blood volume decrease, while heart rate and blood
pressure are still within normal range.
_________ therapy is now suggested for fluid resuscitation to replace patient losses,
including administering PRBCs, plasma, and platelets. - ansCOMPONENT THERAPY
ch. 5, p. 45
__________, which can occur in resuscitation, is a common IATROGENIC cause of
INCREASED intrathoracic pressure resulting in COMPRESSION of the heart and
DECREASED cardiac output. - ansHYPERVENTILATION
ch. 7, p. 74
55% of spinal injuries occur to which part of spine? - anscervical
ch. 13, p. 179
A rapid, thready pulse may indicate (a. _______), and an irregular pulse may warn of
potential (b. _______). - ansa. HYPOVOLEMIA
b. CARDIAC DYSFUNCTION
ch. 5, p. 45

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TNCC TRAUMA NURSING CORE
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ABGs provide values of oxygen, CO2 and base excess, which are... - ansReflective
endpoint measurements of the effectiveness of cellular perfusion, adequacy of
ventilation, and the success of the resuscitation.
An abnormal base deficit may indicate poor perfusion and tissue hypoxia, which results
in the generation of hydrogen ions and metabolic acidosis.
ch. 5, p. 46
Activation of the SYMPATHETIC NERVOUS SYSTEM causes the ADRENAL glands to
release TWO catecholamines - EPINEPHRINE and NOREPINEPHRINE. These
cause... - ans- HIGH levels of EPINEPHRINE cause smooth muscle relaxation in the
airways and causes arteriole smooth muscle contractility (potentiating inotrophic effect).
EPI also INCREASES heart rate (positive chronotrophic effect), peripheral
vasocontriction, and glycogenolysis (breakdown of glycogen stores in liver into glucose
for cellular use)
- NOREPINEPHRINE increases heart rate, vascular tone through alpha-adrenergic
receptor activation, and blood flow to skeletal muscle and triggers the release of
glucose from energy stores.
ch. 7, p. 77
Additional history includes the following (MIST mnemonic) prehospital report: - ans- MOI
- Injuries sustained
- Signs and Symptoms (in the field)
- Treatment (in the field)
ch. 5, p. 47
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

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TNCC TRAUMA NURSING CORE
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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

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TNCC TRAUMA NURSING CORE
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Assessment findings for MILD, MODERATE, and SEVERE TRAUMATIC BRAIN
INJURY INCLUDE: - ansMILD
- 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

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- 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
- 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)

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