NUR 2755 Multidimensional Care IV

NUR 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/ blisters Pt 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 pain Assessing 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 & forth Pt 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 develop Pt 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