NUR2755 / NUR 2755 FINAL EXAM (Latest Update ): Multidimensional Care IV / MDC 4 – Rasmussen

NUR2755 / NUR 2755 FINAL EXAM (Latest Update ): Multidimensional Care IV / MDC 4 - RasmussenNUR 2755 Multidimensional Care IV MDC4 FINAL EXAM what are the treatments for frostbite in the ED? - Warm saline, immerse hands/feet in warm water, elevate affected limbs, have them rub their hands together Priority treatment for pt with a heat stroke - Move them out of the sun, into shade First priority assessment - Airway Process called for sorting patients - Triage Pt with a heat stroke starts to shiver. Why is this this bad? - Raises their temp.; give them meds Pt has an increased temp., what will we tell the UAP to do? - Strip them down/remove clothing 2nd degree frost bite looks like? - Milky fluid, red w/ blistersPt w/ heat stroke--what characteristics would we see in the pt? - Tachycardia, irregular pulse patter, visual disturbance, dec. urine output Pt being treated for hypothermia & is on a heart monitor. What is the reason that the pt could have arrhythmias? - Lactic acid shunted Pt sustained a blunt trauma to the chest, sign that the pt has a pneumothorax? - Diminished breath sounds Low pressure alarms on the ventilator, what do we think happened/what do we do? - It disconnected; ventilate the pt manually Pt w/ rib fracture, how would they present? - Pain on inspiration Most distinctive sign of flailed chest? - Paradoxical chest movement Pt has a high-pressure alarm on the ventilator & absence of breath sounds on the right lower lobe. what do they have? - Pneumothorax Earliest signs of respiratory distress? - Increased resp rate; 20 Most common symptoms of a pt w/ a PE? - Sudden chest painAssessing pain for pt who is unconscious, what's the first intervention? - Nail bed pressure Pt with a head injury & are arousable, what is one intervention the pt can do themselves to reduce ICP? - Exhaling during repositioning Characteristics of CSF, what does it test for? - Clear w/ a yellow halo; tests positive for glucose How can we limit autonomic dysreflexia? - Routine bowel & bladder program Evaluating a pt for a spinal cord injury; which of the following would indicate shock? - Flaccid paralysis Can restraints be used if a pt had a seizure? - No Pt with hemianopia, what do we recommend to help overcome their deficit? - Scanning back & forth Best thing to teach pt w/ Myasthenia gravis, regarding their medications - Continue taking meds to maintain blood level Pt w/ Parkinson's w/ bradykinesia--what to teach them for getting out of a chair? - Rock back & forthPt that has Guillain Barre syndrome--what do we want to know about them? - If they have a hx/exposure of epstein-barr virus Pt w/ Guillain Barre & have been intubated; what is the plan of care for the pt to cope w/ this illness? - Provide info, give positive feedback, & encouraged relaxation What is the neurological sign for meningitis? - Brudzinski sign Pt instructions do we give a pt w/ a halo device? - Drink w/ a straw, inform pt the device will change their equilibrium/balance, wash under the wool skin Triage the following: - Infant w/ petecchiae/104 temp, pt w/ minor head wound, pt w/ abd pain, & pt w/ ankle injury Giving food to a pt with hemiparesis and has hemiplegia? - Offer food on the unaffected side What is the long-term reaction to Dilantin/phenytoin use? - Gum hyperplasia Pt that is on Dilantin long-term, what might happen if they abruptly d/c? - Status epilepticus would developPt is in the postictal phase of a tonic-clonic seizure, what will they look like? - Tired & drowsy Priority assessment in pt in the postictal phase? - Airway Give instructions/education to a pt going to receive and EEG, can they have anything with caffeine? - NO caffeine What would we observe in a pt in the ictal phase? - Loss of awareness, rigidity; stiffness, violent muscle contractions Decerebrate posturing? - The back is arched & all 4 extremities are rigidly extended What is the desired PTT for heparin therapy? - 60 Pt with a PTT of 25 seconds, what would we do? - Increase heparin Pt is genetically predisposed to a PE; what would we expect to do? - Teaching for an IVC filter Pt has a massive blood loss from trauma, what will you expect to see in their MAP? - It will dropPt's RR was 12 and is now at 16, HR 80 and now 92, what is the priority action? - Continue to monitor/document findings Pt's WBC: 3.8, BS: 198, Temp: 96.2, what is the priority action? - Call MD about the temperature. One thing to give instructions on for older adults in a community to prevent dehydration - Inc. fluid intake/drink more water Number 1 lab to look at when evaluating shock - Lactic acid Ways to prevent PTSD - Well balanced meal, drink fluids, take a break when need to, don't work 12 hrs a day, debrief During a mass casualty, a pt with multiple rib fractures & SOB would get one color tag? - Red You are a charge nurse in the ED & getting staff calls and bickering after a week of numerous traumas, what is the first action? - Debriefing Pt is found unresponsive in their home & their skin is bright cherry red. What do you suspect happened? What lab to get? - Carbon monoxide poisoning; carboxyhemoglobin