NSG233 - Exam 1 Study Guide
1. mass casualty prioritization: - green (minor injury, can wait)
-yellow (severe injury, not in danger of dying)
-red (need immediate care to avoid death)
-blue (pending death)
-black (dead)
2. hospital triage levels (emergency severity index): - 1: critical, most in danger of dying
(resuscitation, sexual assault, needs to be seen immediately)
-2: emergent (may wait 10-15 minutes)
-3: urgent (need 3+ resources, but can wait)
-4: non-urgent (needs 1-2 resources)
-5: referred (no resources needed)
3. What are the priorities for a violent patient in the ED with a gun?: - run
-hide
-fight
4. How does the nurse assess for intimate partner violence or trafficking during
evaluation?: - attempt to get patient alone
-ask about feeling safe at home
-be aware of withdrawn demeanor
5. critical incident stress management (CISM): system that provides education and resources to prevent
stress and to deal with stress appropriately when it occurs at the hospital (following pediatric death, shooting, death of patient known
to caregiver)
6. primary survey: rapidly identify and begin interventions for immediate threat to life
7. components of primary survey: - airway (cervical spine stabilization)
-breathing
-circulation
-disability (quick neuro GCS)
-exposure (remove clothes)
8. secondary survey: additional assessment to determine the existence of any non-threatening injuries other than those
found in the primary survey (head-to-toe)
9. components of secondary survey: - health history
-head-to-toe assessment
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, -diagnostic and lab testing
-monitoring devices
-splinting
-wound care
10. Glasgow Coma Scale: - eye, verbal, motor
-max score = 15 pts
-below 8 = coma (less than 8, intubate)
-min score = 3 (a rock can be a 3)
11. heat cramps - LATTEE: L: severe muscle cramps, sweating, nausea, paleness, weakness A:
vital signs, temp, LOC, RR, cardiovascular status, skin
T: EKG, CBC
T: cool blankets, IV access, oral fluids, rest, massage, NSAIDs E:
E:
12. heat exhaustion - LATTEE: L: hypotension, elevated temp, confusion, sweating, headache, tachycardia,
extreme thirst, N/V, dizziness
A: vital signs, temp, LOC, skin, cardiovascular
T: CBC (electrolytes), CMP (renal, liver), urine output T:
shade, A/C, ice packs to groin/axilla, IV fluids
E:
E:
13. heat stroke - LATTEE: L: hot dry skin, no sweating, vasodilation, hallucinations, delirium
A: vital signs
T: ABG
T: IV fluids, avoid shivering E:
E: avoid exercise for 7 days, teach S/S of heat related illness
14. symptoms of stages of Lyme disease: - I: bull's eye rash at site of bite, flu-like symptoms (7 days to 4
weeks after bite)
-II: facial nerve palsy, joint pain, memory loss (4-10 weeks after bite)
-III: arthritis, neuropathy, myocarditis (weeks to years after bite)
15. clinical manifestations of pulmonary contusion: - dyspnea
-respiratory distress
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1. mass casualty prioritization: - green (minor injury, can wait)
-yellow (severe injury, not in danger of dying)
-red (need immediate care to avoid death)
-blue (pending death)
-black (dead)
2. hospital triage levels (emergency severity index): - 1: critical, most in danger of dying
(resuscitation, sexual assault, needs to be seen immediately)
-2: emergent (may wait 10-15 minutes)
-3: urgent (need 3+ resources, but can wait)
-4: non-urgent (needs 1-2 resources)
-5: referred (no resources needed)
3. What are the priorities for a violent patient in the ED with a gun?: - run
-hide
-fight
4. How does the nurse assess for intimate partner violence or trafficking during
evaluation?: - attempt to get patient alone
-ask about feeling safe at home
-be aware of withdrawn demeanor
5. critical incident stress management (CISM): system that provides education and resources to prevent
stress and to deal with stress appropriately when it occurs at the hospital (following pediatric death, shooting, death of patient known
to caregiver)
6. primary survey: rapidly identify and begin interventions for immediate threat to life
7. components of primary survey: - airway (cervical spine stabilization)
-breathing
-circulation
-disability (quick neuro GCS)
-exposure (remove clothes)
8. secondary survey: additional assessment to determine the existence of any non-threatening injuries other than those
found in the primary survey (head-to-toe)
9. components of secondary survey: - health history
-head-to-toe assessment
1/
7
, -diagnostic and lab testing
-monitoring devices
-splinting
-wound care
10. Glasgow Coma Scale: - eye, verbal, motor
-max score = 15 pts
-below 8 = coma (less than 8, intubate)
-min score = 3 (a rock can be a 3)
11. heat cramps - LATTEE: L: severe muscle cramps, sweating, nausea, paleness, weakness A:
vital signs, temp, LOC, RR, cardiovascular status, skin
T: EKG, CBC
T: cool blankets, IV access, oral fluids, rest, massage, NSAIDs E:
E:
12. heat exhaustion - LATTEE: L: hypotension, elevated temp, confusion, sweating, headache, tachycardia,
extreme thirst, N/V, dizziness
A: vital signs, temp, LOC, skin, cardiovascular
T: CBC (electrolytes), CMP (renal, liver), urine output T:
shade, A/C, ice packs to groin/axilla, IV fluids
E:
E:
13. heat stroke - LATTEE: L: hot dry skin, no sweating, vasodilation, hallucinations, delirium
A: vital signs
T: ABG
T: IV fluids, avoid shivering E:
E: avoid exercise for 7 days, teach S/S of heat related illness
14. symptoms of stages of Lyme disease: - I: bull's eye rash at site of bite, flu-like symptoms (7 days to 4
weeks after bite)
-II: facial nerve palsy, joint pain, memory loss (4-10 weeks after bite)
-III: arthritis, neuropathy, myocarditis (weeks to years after bite)
15. clinical manifestations of pulmonary contusion: - dyspnea
-respiratory distress
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