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CCRN ADULT III LEAKED TEST 2025 VERIFIED
QUESTIONS AND CORRECT ANSWERS GRADED
A+.
Cushing's response - correct answer>>The brain's attempt to restore blood flow by increasing arterial pressure to overcome increased intracranial pressure. Cushing's triad - correct answer>>A result of brain stem herniation. What pressure is required to perfuse the brain? - correct answer>>at least 80 mmHg Normal is (70)- 80 - 100 mmHg Neuro Focused Assessment - correct answer>>q1h --Glasgow Coma Scale / LOC --Pupillary Responses --Motor Function --Vital Signs --Reflexes Glasgow Coma Scale - correct answer>> Protective Reflexes - correct answer>>Indicate basic brainstem function! --Corneal/blink
--Gag reflex --Swallowing reflex --Cough reflex Deficits are very discouraging Dolls eyes - correct answer>>Reflex assessed in comatose patient Normal: Eyes will move toward opposite site in comatose patient Absent reflex: Fixed eyes are bad and indicate loss of brainstem function! Cold caloric response - correct answer>>Normal:Pt will look toward the ear injected Absent reflex: BAD sign, usually a lesion in the pons or medulla Abnormal: look away or opposite, if patient partially awake. What is normal ICP? - correct answer>> 0 - 15 mmHg
20 is concerning What can we do to limit increased ICP? - correct answer>>--Decrease fluid volume --HOB @ 30 degrees --craniotomy to relieve pressure Contraindications for ICP Monitoring - correct answer>>--Infection --Coagulopathy (impaired clotting) ICP monitoring systems - correct answer>>--Intraventricular (ventriculostomy) --Subarachnoid --Epidural/subdural --Fiber optic transducer tipped catheter
Late signs of rising ICP - correct answer>>--decreased pupil reactivity --Cushing's triad --decorticate/decerebrate posturing --diminished brainstem reflexes (ice, nailbed test) Management of increased ICP - correct answer>>--Calm, quiet, dark room (don't bother them all the time) --HOB 30° (Avoid positions that decrease venous return from the brain; keep them midline) --CSF Drainage - open (rising ICP) vs. closed (cant drain too much) --Sedation --Hypertonic saline (draw fluid out of brain tissue) (3%) via central line Why might Propofol be used for sedation in patients with elevated ICP? - correct answer>>Has properties that lower ICP Why are osmotic diuretics used in patients with elevated ICP? - correct answer>>Draws out fluid from brain tissue Subdural hematoma - correct answer>>--Usually a venous bleed --Much slower decline in status Epidural hematoma - correct answer>>--Arterial or venous bleed --Arterial can cause rapid decline in status Coup-Countercoup - correct answer>>Injury caused by acceleration AND deceleration of the brain Diffuse Axonal Injury - correct answer>>--Several small bleeds in brain leading to swelling --Very hard to treat and often has devastating outcomes (e.g. persistent veg. state)
Priorities in management of TBI - correct answer>>--Stabilizing vital signs - Preventing further injury --Reducing increases in ICP and maintaining adequate cerebral perfusion pressure --Always be ready to travel to CT or OR emergently. Craniotomy - correct answer>>Performed to gain access to portions of the CNS inside the cranium Indications for Craniotomy - correct answer>>--Tumor resection or removal --Cerebral decompression --Evacuation of hematoma or abscess --Clipping or removal of an aneurysm or arteriovenous malformation Post-op Craniotomy Concerns - correct answer>>--Intracranial hypertension --Surgical hemorrhage --Fluid imbalance --CSF leak --DVT prophylaxis Ischemic (brain attack) stroke - correct answer>>Decreased blood flow --Thrombolytic therapy - within 4.5 hours of onset of ischemic strokes Hemorrhagic stroke - correct answer>>Rupture and bleed into tissue --NO Thrombolytic therapy because of bleeding Subarachnoid Hemorrhage (SAH) - correct answer>>Usually caused by a ruptured aneurysm or Arterio-venous Malformation (AVM)
Breathing and ventilation: patterns/gas exchange Circulation and hemorrhage control: decreased O2, impaired tissue perfusion, deficient fluid volume Disability and neurologic status Exposure/environmental control Trauma Care: Resuscitation phase - correct answer>>Concurrent with primary survey* Hypovolemic shock from hemorrhage
- Fluid bolus with IVFs (0.9% Saline or Lactated Ringers)
- O Neg or Type-specific blood
- Massive transfusion protocol IV Access
- Two large bore (14-16 G) peripheral IVs
- IO (intraosseaous)
- Central line Foley
- Monitor urine output/kidney perfusion NGT/OGT
- Gastric decompression, prevent aspiration AMPLE - correct answer>>Secondary survey Allergies Medications currently used Past medical history Last meal Events/environment related to injury
Primary Survey - correct answer>>Patient stablization Secondary Survey - correct answer>>"Nice to know", but not essential The events that led up to the injury Trauma Care: Operative phase - correct answer>>--Off to the OR, fix what is fixable (i.e. most critical injuries) --If unstable, operate in trauma bay --May not be able to operate, may just be able to "contain" injury and observe & off to the ICU (i.e. liver injury) Trauma Care: Critical Care Phase - correct answer>>Priority nursing care includes ongoing physical assessments and monitoring response to medical therapies (need good report and vigilance) Complete Spinal Cord Injury - correct answer>>If afferent and efferent signals are unable to get through More catastrophic Incomplete Spinal Cord Injury - correct answer>>More common; mixed pattern of partial motor, sensory and reflex function Anterior Cord Syndrome - correct answer>> Central Cord Syndrome - correct answer>> Brown-Sequard Syndrome - correct answer>> Spinal Cord Mechanisms of injury - correct answer>>Hyperflexion: Head on collisions/diving
TLSO (Clam shell brace) - correct answer>>used to hold the thoracic (chest) part of your spine immobile. Management After Spinal Cord Injury - correct answer>>--Preventing secondary damage to the spinal cord --Managing cardiovascular and pulmonary complications --Coaching the patient to overcome the psychosocial challenges associated with severe neurologic deficit --Manage skin breakdown --Log roll only --Self-cath teaching if needed Flail Chest - correct answer>>Result of traumatic injury Trachea and heart displaced to the opposite side Ruptured Diaphragm - correct answer>>--Result of compression force applied to the lower part of the chest or upper abdominal region --Thrown forward over the edge of the steering wheel in high speed MVC w decelerating forces --Abdominal contents can enter the thoracic cavity (and compress the heart and lungs) --May hear bowel sounds in chest cavity Pulmonary contusion - correct answer>>A contusion (bruise) of the lung, caused by chest trauma. As a result of damage to capillaries, blood and other fluids accumulate in the lung tissue. The excess fluid interferes with gas exchange, potentially leading to inadequate oxygen levels (hypoxia). Tension pneumothorax - correct answer>>Caused by an injury that perforates the chest wall or pleural space. Air flows into the pleural space with inspiration and becomes trapped. As pressure in the pleural space
increases, the lung on the injured side collapses and causes the mediastinum to shift to the opposite side. 2 types of Chest Tube Drainage Systems - correct answer>>1. Wet system
- Dry system - up to 40 cm suction (used more often because of high suction capabilities) Wet system - correct answer>>Blue - Water seal chamber; filled w/ water Red - Air leak meter; filled with water (bubbling always bad; constant = bad leak, intermittent = slight leak) White - Drainage, gentle bubbling normal Dry system - correct answer>>No water seal chamber; replaced by orange indicator Water seal chamber/air leak chamber in Wet system - correct answer>>Tidling (rise with inspiration; lowering with expiration) is okay; constant bubbling is not. no tidling might be an obstruction. Bubbling in the red is always bad as it signifies leak Water seal chamber/air leak chamber in Dry system - correct answer>>No water seal chamber; Bubbling in the red is always bad as it signifies leak Emergency Equipment bedside for chest tube - correct answer>>--Sterile water (to place tube in if it becomes disconnected) --Occlusive dressing, tape, and Vaseline gauze if tube comes out of chest --Tube clamps (only if the chest tube had to be changed out)
What are the s/s of a spleen injury? - correct answer>>--LUQ tenderness (only 50% of the time) --hold L shoulder elevated for comfort --"Kehr's sign" Treatment of Splenic Laceration or Hematoma - correct answer>>[Grade I- III] --NPO --IV fluids --Q6h H&H (to check evolution of bleeding) --Watch for tachycardia & hypotension --BEDREST with bedpan [Grade IV-V] --surgery (coil embolization)
What are the s/s of a liver injury? - correct answer>>--Severe abd pain (more on inspiration because diaphragm descends and touches the liver) --Tachycardia/hypotension (blood loss) --Anxiety Treatment of Liver Injury - correct answer>>[Grade I-IV] --NPO --IV fluids --BEDREST --coil embolization [Grade IV-V] --surgery for packing, return trips, try to save the as much of the organ as possible Lab trends of failed management of Spleen/Liver injury - correct answer>>Falling hematocrit --Increasing abdominal pain --Hemodynamically unstable --Required transfusion of 2 or more units of blood Patient is sent to the OR What is the primary cause of bladder trauma? - correct answer>>Pelvic fractures What do we have to monitor closely with bladder trauma? - correct answer>>STRICT output, color, and quality of urine from foley cath What might dark tea colored urine indicate? - correct answer>>Myoglobinuria
Chemical Burns - correct answer>>--Tissue damage continues until agent completely removed or neutralized --Pulmonary Inhalation a concern Upper Airway Injury - correct answer>>--Supraglottic (above glottis) from heat or chemicals --Upper airway edema peaks at 24-48 hours post injury --Look for facial burns, singed nasal hair, erythema, swelling, tachypnea, dyspnea, hoarseness, brassy cough, stridor Give humidified 100% oxygen via face mask Lower Airway Injury - correct answer>>--Usually result of toxic gases and chemicals from inhaled smoke --When contact with pulmonary tissue: irritation, inflammatory reaction resulting in edema, secretions, decreased ciliary action, bronchospasm, inactivation of surfactant, atelectasis (damage to alveoli) --Treatment is supportive: humidified O2 at 100% --Meticulous pulmonary toilet (get the excriment out of lungs) to prevent ARDS Carbon Monoxide Poisoning - correct answer>>--Knocks oxygen off hemoglobin --Pulse ox is unreliable (still saturated, but with CO2) --Check carboxyhemoglobin levels (15-40% =restless & confusion, CNS dysfunction; 40-60%=loss of consciousness; > 60%=death) --Hyperbaric oxygen to treat First degree (superficial thickness) burn - correct answer>>--Involves only the first layer of skin epidermis only (e.g. sunburn)
--Skin is pink/red with mild edema --nerves intact = pain --Heal without treatment or scarring in 3-6 days Second Degree (partial thickness) burn - correct answer>>--Epidermis & portion of dermis --Characteristics: blister formation, pink or mottled red, pain --Cause: scald, flash flame --Complications rare, minimal scarring unless infected --nerves intact = pain --Healing Time: within 21 days Second Degree (DEEP partial thickness) burn - correct answer>>--Epidermis and dermis Characteristics: pale, mottled, insensate, white/waxy, ESCHAR -- Conversion to full-thickness by bacteria, scarring is common --nerves intact = pain --Skin grafting improves quality & appearance --Healing time: within 3-6 wks Third degree (full thickness) burn - correct answer>>--Epidermis, dermis & underlying subcutaneous tissue --No potential for re-epithelialization --Skin grafting required for wound closure --Characteristics: range in color from pale to bright red. Little to no cap refill. leathery eschar, white or charred black tissue, insensate. Why can bacteria cause a burn to get deeper? - correct answer>>Bacteria can eat good tissue making burn worse Circumferential Burns - correct answer>>Sign of abuse
--Prevent Respiratory Distress --Prevent Shock --Detect & treat concomitant injuries Burn Care: Resuscitative Phase - correct answer>>Continue to assess A, B, C, D, C-spine, history --Assess for circumferential burns --Indwelling urinary catheter placement --CXR, Laboratory values --NGT placement --Pain control --Estimate Injury (BSA) --Fluid resuscitation --Tetanus toxoid administration Burn Shock - correct answer>>↓Blood Volume ↓Blood Pressure ↓Cardiac Output ↓Tissue Perfusion ↑Heart Rate ↑SVR/vasoconstriction Parkland Formula - correct answer>>First 24 hrs post-burn: 2 to 4 ml of Lactated Ringer's solution/kg/% of TBSA burned ½ given in 1st 8 hrs ½ given over next 16 hours 3 - 4 ml of IVF x Wt. in kg x % body burn Give (½) of total volume during 1st 8 hrs Give (¼) of total volume during 2nd 8 hrs Give (¼) of total volume during 3rd 8 hrs
Parkland Formula example - correct answer>>time of injury, not time of hospital admission 4 x 50 kg (110 lbs) x 20% = 4,000 ml 1st 8 hrs: IVF= 2,000ml /8 hrs =250 ml/hr then 125/hr x8 hrs, then 125/hr x8 hrs Burn pain - correct answer>>--Full-thickness are usually insensate, except at edges --Partial-thickness are exceptionally sensitive --Relief of Pain and anxiety are crucial --Morphine and Fentanyl are most commonly used Wound Cleansing - correct answer>>Wound debridement --Irrigation --Biological (maggots) --Chemical (enzyme) --Surgical Wound Healing - correct answer>>--Hypermetabolic state: total energy needs can be 100 times normal --Use GI tract early (within 24 hours is ideal!) --Vitamin supplements Brain Death - correct answer>>Irreversible loss of all brain function including the brainstem 3 Essential findings of brain death - correct answer>>--Coma: absence of cerebral motor response in all extremities in response to noxious stimuli - Absence of brainstem reflexes: no pupillary response, occulocephalic (dolls eyes) occulovestibular reflex, corneal jaw, grimace to noxious stimuli - Apnea Test
