NUR 265 Exam 3 | Questions and Answers |
Fall 2025/26 Update | 100% Correct.
What causes Autonomic Dysreflexia - Answer - Stimulation at level of T6 or above
What are some examples of triggers of autonomic dysreflexia - Answer - restrictive clothing;
full bladder/neurogenic bladder; fecal impaction; directive pressure s/a sitting in the wheel
chair
signs and systems of Autonomic Dysreflexia - Answer - hypertension, flushed face,
headaches, JVD, bradycardic, diaphoresis, pale ext below the level of T6, nausea, dilated
pupils, blurred vision, restlessness
What is the purpose of fluid resuscitation for a burn victim - Answer - maintain vital organ
perfusion, reduce edema, minimize effects of fluid shifts, prevent hypovolemic shock
What IV solution is commonly used to resuscitate a pt with a burn - Answer - Lactated
ringers
Chemical burns should be irrigated until - Answer - 20 minutes or the burn sensation
continues after the 20 minute marker
what would you use to remove hot tar or asphalt - Answer - citrus petroleum jelly ex;
medisol
petroleum jelly
antibiotic ointment
what kind of brain injury would you expect if an adult client is positive for Palmer's infant
reflexes - Answer - cortical and premotor cortex damage
what kind of brain injury would you expect if an adult client is positive for plantar infant
reflexes - Answer - upper motor neuron lesion
what kind of brain injury would you expect if an adult client is positive for rooting infant
reflex - Answer - frontal lobe damage
what kind of brain injury would you expect if an adult client is positive for sucking infant
reflex - Answer - Advance dementia; cortical brain damage
,what kind of brain injury would you expect if an adult client is positive for glabella
(persistent blinking) infant reflex - Answer - diffuse cortical dysfunction
What is the consensus formula for burns - Answer - 2-4 ml X TBSA X KG
What S&S are expected for a burn client who is receiving the first 8 hours of fluid
resuscitation - Answer - Restlessness, anxiety, Hypothermia
how much fluid replacement are you going to give the first 8 hours - Answer - 1/2 of the fluid
consensus
What do you need to monitor when resuscitating fluids for burn pt to make sure that it is
working - Answer - Urine output
Besides a hyperbaric chamber how would you admin o2 to a client with CO poisoning -
Answer - 100% O2 with a non-rebreather
How would you treat a circumferential trunk burn that is swelling and why? - Answer -
Eschartomies R/T constriction of the chest wall expansion
what are the classification of shock - Answer - Cardiogenic; hypovolemic, neurogenic, and
Disruptive
All shock is caused by - Answer - inadequate tissue perfusion
Patho of hypovolemic shock - Answer - Inadequate circulating blood volume S/A burns,
hemorrhage, dehydration
Patho for cardiogenic shock - Answer - Inadequate pumping action of the heart S/A MI, CHF,
PE
What are the 3 subclasses of Distributive shock - Answer - Anaphylactic; Septic; Neurogenic
Patho for neurogenic shock - Answer - interference of the nervous system that controls the
blood vessels
Patho for septic shock - Answer - Release of vasoactive substance from the immune system
How much blood loss is required for the patient to be at high risk for hypovolemic shock -
Answer - 15-25%, or 1/3 of the body blood, or 5L
clients who experience slow blood loss can - Answer - Tolerate the blood loss better then a
client with rapid blood loss
Signs and symptoms of compensatory shock - Answer - hypotension, tachycardia, tachypnea,
hypothermia, decrease pulse pressure
During compensatory stage of shock, why would you hear hypoactive bowl sounds and cool
and clammy skin - Answer - Body shunting blood from skin, kidneys and GI to provide
adequate blood volume to the brain and heart
, Why would urine output decrease during compensatory stage of shock - Answer - High
production of aldosterone
why do RR increase in compensatory stage of shock - Answer - The body is going into
acidotic state trying to blow it off Kussmals
What is the byproduct of anaerobic metabolism that is developing in what stage of shock -
Answer - Lactic acid, Compensatory
Why would you not give someone with impaired hepatic function lactated ringers - Answer -
Because it does not convert lactic acid into bicarb fast enough could go into acidosis
why would you check for high levels of sodium nd glucose in the compensatory stage of
shock - Answer - Because of the release of alderstone and catecholamines which is used to
regulate blood volume
What stage of shock that lactic acid is at the highest - Answer - progressive
What happends to the body when build up of lactic acid occurs - Answer - increase capillary
permeability; relaxation of capillary spincter; blood is retaining in the cap beds
S&S of the progressive stage of shock - Answer - Hypoxia, alveolar collapse, pulmonary
edema, cardiac dysrhythmias, ischemic heart, ARF, DIC, Mental status change
Patho of the progressive stage of shock - Answer - organ suffering from hypoxia,
vasoconstriction decrease cell perfusion, GFR cannot be maintained
How do you calculate MAP - Answer - Systolic (2 X diastolic) / 3
Manis of shock - Answer - decrease LOC, Confusion, pale mottled cool skin, poor skin turgor,
cyanosis(late) Delay cap refill, decrease UO, CO, and BP, rapid and threadie pulse, increase
RR, dyspnea, diaphoresis, hypothermia
Septic shock can lead to - Answer - SIRS
S&S of Hypovolemic shock - Answer - decrease urine osmolality, and SG (R/T NA and H2O
retention), increase SNS response (S/A rapid RR increase pulse rate.) Decrease tissue
perfusion, Pale appearance, diaphoretic, cyanosis(late)
Pt with a hernia repair comes back post op VS; 99/50 HR; 115 RR; 28, Pain 5 O2 89% - What
would you do first - Answer - 1) Treat O2 levels by Raising HOB and applying O2
2) Treat hypotension; Fluid replacement (LR)
3) manage pain
What will determine what you would do for your patient first - Answer - the results of your
head to toe assessment.
Fall 2025/26 Update | 100% Correct.
What causes Autonomic Dysreflexia - Answer - Stimulation at level of T6 or above
What are some examples of triggers of autonomic dysreflexia - Answer - restrictive clothing;
full bladder/neurogenic bladder; fecal impaction; directive pressure s/a sitting in the wheel
chair
signs and systems of Autonomic Dysreflexia - Answer - hypertension, flushed face,
headaches, JVD, bradycardic, diaphoresis, pale ext below the level of T6, nausea, dilated
pupils, blurred vision, restlessness
What is the purpose of fluid resuscitation for a burn victim - Answer - maintain vital organ
perfusion, reduce edema, minimize effects of fluid shifts, prevent hypovolemic shock
What IV solution is commonly used to resuscitate a pt with a burn - Answer - Lactated
ringers
Chemical burns should be irrigated until - Answer - 20 minutes or the burn sensation
continues after the 20 minute marker
what would you use to remove hot tar or asphalt - Answer - citrus petroleum jelly ex;
medisol
petroleum jelly
antibiotic ointment
what kind of brain injury would you expect if an adult client is positive for Palmer's infant
reflexes - Answer - cortical and premotor cortex damage
what kind of brain injury would you expect if an adult client is positive for plantar infant
reflexes - Answer - upper motor neuron lesion
what kind of brain injury would you expect if an adult client is positive for rooting infant
reflex - Answer - frontal lobe damage
what kind of brain injury would you expect if an adult client is positive for sucking infant
reflex - Answer - Advance dementia; cortical brain damage
,what kind of brain injury would you expect if an adult client is positive for glabella
(persistent blinking) infant reflex - Answer - diffuse cortical dysfunction
What is the consensus formula for burns - Answer - 2-4 ml X TBSA X KG
What S&S are expected for a burn client who is receiving the first 8 hours of fluid
resuscitation - Answer - Restlessness, anxiety, Hypothermia
how much fluid replacement are you going to give the first 8 hours - Answer - 1/2 of the fluid
consensus
What do you need to monitor when resuscitating fluids for burn pt to make sure that it is
working - Answer - Urine output
Besides a hyperbaric chamber how would you admin o2 to a client with CO poisoning -
Answer - 100% O2 with a non-rebreather
How would you treat a circumferential trunk burn that is swelling and why? - Answer -
Eschartomies R/T constriction of the chest wall expansion
what are the classification of shock - Answer - Cardiogenic; hypovolemic, neurogenic, and
Disruptive
All shock is caused by - Answer - inadequate tissue perfusion
Patho of hypovolemic shock - Answer - Inadequate circulating blood volume S/A burns,
hemorrhage, dehydration
Patho for cardiogenic shock - Answer - Inadequate pumping action of the heart S/A MI, CHF,
PE
What are the 3 subclasses of Distributive shock - Answer - Anaphylactic; Septic; Neurogenic
Patho for neurogenic shock - Answer - interference of the nervous system that controls the
blood vessels
Patho for septic shock - Answer - Release of vasoactive substance from the immune system
How much blood loss is required for the patient to be at high risk for hypovolemic shock -
Answer - 15-25%, or 1/3 of the body blood, or 5L
clients who experience slow blood loss can - Answer - Tolerate the blood loss better then a
client with rapid blood loss
Signs and symptoms of compensatory shock - Answer - hypotension, tachycardia, tachypnea,
hypothermia, decrease pulse pressure
During compensatory stage of shock, why would you hear hypoactive bowl sounds and cool
and clammy skin - Answer - Body shunting blood from skin, kidneys and GI to provide
adequate blood volume to the brain and heart
, Why would urine output decrease during compensatory stage of shock - Answer - High
production of aldosterone
why do RR increase in compensatory stage of shock - Answer - The body is going into
acidotic state trying to blow it off Kussmals
What is the byproduct of anaerobic metabolism that is developing in what stage of shock -
Answer - Lactic acid, Compensatory
Why would you not give someone with impaired hepatic function lactated ringers - Answer -
Because it does not convert lactic acid into bicarb fast enough could go into acidosis
why would you check for high levels of sodium nd glucose in the compensatory stage of
shock - Answer - Because of the release of alderstone and catecholamines which is used to
regulate blood volume
What stage of shock that lactic acid is at the highest - Answer - progressive
What happends to the body when build up of lactic acid occurs - Answer - increase capillary
permeability; relaxation of capillary spincter; blood is retaining in the cap beds
S&S of the progressive stage of shock - Answer - Hypoxia, alveolar collapse, pulmonary
edema, cardiac dysrhythmias, ischemic heart, ARF, DIC, Mental status change
Patho of the progressive stage of shock - Answer - organ suffering from hypoxia,
vasoconstriction decrease cell perfusion, GFR cannot be maintained
How do you calculate MAP - Answer - Systolic (2 X diastolic) / 3
Manis of shock - Answer - decrease LOC, Confusion, pale mottled cool skin, poor skin turgor,
cyanosis(late) Delay cap refill, decrease UO, CO, and BP, rapid and threadie pulse, increase
RR, dyspnea, diaphoresis, hypothermia
Septic shock can lead to - Answer - SIRS
S&S of Hypovolemic shock - Answer - decrease urine osmolality, and SG (R/T NA and H2O
retention), increase SNS response (S/A rapid RR increase pulse rate.) Decrease tissue
perfusion, Pale appearance, diaphoretic, cyanosis(late)
Pt with a hernia repair comes back post op VS; 99/50 HR; 115 RR; 28, Pain 5 O2 89% - What
would you do first - Answer - 1) Treat O2 levels by Raising HOB and applying O2
2) Treat hypotension; Fluid replacement (LR)
3) manage pain
What will determine what you would do for your patient first - Answer - the results of your
head to toe assessment.
