TNC FULL EXAM AND ANSWER
Why is a measure of serum lactate obtained in the initial assessment of the
trauma patient?
Answer: c
a) to measure oxygenation and ventilation
b) to quantify the base deficit for the adequacy of cellular perfusion
c) to gauge end-organ perfusion and tissue hypoxia *
d) to determine the underlying cause of shock
A trauma patient is restless and repeatedly asking "where am I?" vital signs upon
arrival were BP 100/60 mm Hg, HR 96 beats/min, and RR 24 breaths/min. Her skin
is cool and dry. Current vital signs are BP 104/84mm Hg, HR 108, RR 28
breaths/min. The patient is demonstrating signs and symptoms of which stage of
shock?
Answer: A
A) compensated **
B) Progressive
C) irreversible
D) decompensated
An elderly patient with a history of anticoagulant use presents after a fall at home
that day. she denies any loss of consciousness. She has a hematoma to her
forehead and complains of headache, dizziness, and nausea. Which is a most
likely cause of her symptoms?
Answer: D
A) epidural hematoma
B) diffuse axonal injury
C) post-concussive syndrome
D) subdural hematoma ***
EMS brings a patient who fell riding his bicycle. Using the American College of
Surgeons screening guidelines, which assessment finding would prompt the
nurse to prepare the patient for radiologic spine clearance?
Answer: D
A) Alert with no neurologic deficits
B) Multiple abrasions to the extremities
C) Multiple requests of water
D) Smell of alcohol on breath ***
Which of the following occurs during the third impact of a motor vehicle crash?
Answer: C
A) The driver of the vehicle collides with the steering wheel
B) the vehicle collides with a tree
, C) the aorta is torn at its attachment with the ligamentum arteriosum
D) the airbag deploys and strikes the front seat passenger ***
A passenger is brought to the emergency department of a rural hospital following
a high-speed MVC. When significant abdominal and pelvic injuries are noted in
the primary survey, which of the following is the priority interventions?
Answer: A
A) initiate transfer to a trauma center **
B) provide report to the operating room nurse
C) Obtained imaging studies
D) Place a gastric tube
Which of the following injuries is LEAST likely to be promptly identified?
Answer: C
A) spleen
B) lung
C) bowel ***
D) brain
Patients with a crush injury should be monitored for which of the following
conditions?
Answer: C
A) Hypernatremia
B) Hypercalcemia
C) Dysrhthmias **
D) polyuria
What finding raises suspicion of complete spinal cord injury?
Answer: B
A) Weakness in the lower extremities
B) Priapism ***
C) voluntary anal sphincter tone
D) intact reflexes distal to the injury
A patient with a complete spinal cord injury in neurogenic shock will demonstrate
hypotension and which other clinical signs?
Answer: D
A) Bradycardia and ipsilateral absences of motor function
B) Tachycardia and respiratory depression
C) Tachycardia and absent motor function below the level of injury
D) Bradycardia and absent motor function below the level of the injury ***
A 5-year old child presents to the ED with bruises to the upper arms and buttocks
in various stages of healing and multiple small, clean, round burns to the back.
There are no abnormalities found based on the pediatric assessment triangle or
primary survey. Which of the following is the priority nursing intervention?
Why is a measure of serum lactate obtained in the initial assessment of the
trauma patient?
Answer: c
a) to measure oxygenation and ventilation
b) to quantify the base deficit for the adequacy of cellular perfusion
c) to gauge end-organ perfusion and tissue hypoxia *
d) to determine the underlying cause of shock
A trauma patient is restless and repeatedly asking "where am I?" vital signs upon
arrival were BP 100/60 mm Hg, HR 96 beats/min, and RR 24 breaths/min. Her skin
is cool and dry. Current vital signs are BP 104/84mm Hg, HR 108, RR 28
breaths/min. The patient is demonstrating signs and symptoms of which stage of
shock?
Answer: A
A) compensated **
B) Progressive
C) irreversible
D) decompensated
An elderly patient with a history of anticoagulant use presents after a fall at home
that day. she denies any loss of consciousness. She has a hematoma to her
forehead and complains of headache, dizziness, and nausea. Which is a most
likely cause of her symptoms?
Answer: D
A) epidural hematoma
B) diffuse axonal injury
C) post-concussive syndrome
D) subdural hematoma ***
EMS brings a patient who fell riding his bicycle. Using the American College of
Surgeons screening guidelines, which assessment finding would prompt the
nurse to prepare the patient for radiologic spine clearance?
Answer: D
A) Alert with no neurologic deficits
B) Multiple abrasions to the extremities
C) Multiple requests of water
D) Smell of alcohol on breath ***
Which of the following occurs during the third impact of a motor vehicle crash?
Answer: C
A) The driver of the vehicle collides with the steering wheel
B) the vehicle collides with a tree
, C) the aorta is torn at its attachment with the ligamentum arteriosum
D) the airbag deploys and strikes the front seat passenger ***
A passenger is brought to the emergency department of a rural hospital following
a high-speed MVC. When significant abdominal and pelvic injuries are noted in
the primary survey, which of the following is the priority interventions?
Answer: A
A) initiate transfer to a trauma center **
B) provide report to the operating room nurse
C) Obtained imaging studies
D) Place a gastric tube
Which of the following injuries is LEAST likely to be promptly identified?
Answer: C
A) spleen
B) lung
C) bowel ***
D) brain
Patients with a crush injury should be monitored for which of the following
conditions?
Answer: C
A) Hypernatremia
B) Hypercalcemia
C) Dysrhthmias **
D) polyuria
What finding raises suspicion of complete spinal cord injury?
Answer: B
A) Weakness in the lower extremities
B) Priapism ***
C) voluntary anal sphincter tone
D) intact reflexes distal to the injury
A patient with a complete spinal cord injury in neurogenic shock will demonstrate
hypotension and which other clinical signs?
Answer: D
A) Bradycardia and ipsilateral absences of motor function
B) Tachycardia and respiratory depression
C) Tachycardia and absent motor function below the level of injury
D) Bradycardia and absent motor function below the level of the injury ***
A 5-year old child presents to the ED with bruises to the upper arms and buttocks
in various stages of healing and multiple small, clean, round burns to the back.
There are no abnormalities found based on the pediatric assessment triangle or
primary survey. Which of the following is the priority nursing intervention?
