NUR 265 TEST 3 UPDATED ACTUAL
Questions and CORRECT Answers
What causes Autonomic Dysreflexia - CORRECT ANSWER Stimulation at level of T6 or
above
What are some examples of triggers of autonomic dysreflexia - CORRECT
ANSWER restrictive clothing; full bladder/neurogenic bladder; fecal impaction; directive
pressure s/a sitting in the wheel chair
signs and systems of Autonomic Dysreflexia - CORRECT 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 - CORRECT
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 - CORRECT
ANSWER Lactated ringers
Chemical burns should be irrigated until - CORRECT ANSWER 20 minutes or the burn
sensation continues after the 20 minute marker
what would you use to remove hot tar or asphalt - CORRECT 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 - CORRECT ANSWER cortical and premotor cortex damage
,what kind of brain injury would you expect if an adult client is positive for plantar infant reflexes
- CORRECT ANSWER upper motor neuron lesion
what kind of brain injury would you expect if an adult client is positive for rooting infant reflex -
CORRECT ANSWER frontal lobe damage
what kind of brain injury would you expect if an adult client is positive for sucking infant reflex -
CORRECT 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 - CORRECT ANSWER diffuse cortical dysfunction
What is the consensus formula for burns - CORRECT 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 -
CORRECT ANSWER Restlessness, anxiety, Hypothermia
how much fluid replacement are you going to give the first 8 hours - CORRECT
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
- CORRECT ANSWER Urine output
Besides a hyperbaric chamber how would you admin o2 to a client with CO poisoning -
CORRECT ANSWER 100% O2 with a non-rebreather
How would you treat a circumferential trunk burn that is swelling and why? - CORRECT
ANSWER Eschartomies R/T constriction of the chest wall expansion
, what are the classification of shock - CORRECT ANSWER Cardiogenic; hypovolemic,
neurogenic, and Disruptive
All shock is caused by - CORRECT ANSWER inadequate tissue perfusion
Patho of hypovolemic shock - CORRECT ANSWER Inadequate circulating blood volume
S/A burns, hemorrhage, dehydration
Patho for cardiogenic shock - CORRECT ANSWER Inadequate pumping action of the
heart S/A MI, CHF, PE
What are the 3 subclasses of Distributive shock - CORRECT ANSWER Anaphylactic;
Septic; Neurogenic
Patho for neurogenic shock - CORRECT ANSWER interference of the nervous system
that controls the blood vessels
Patho for septic shock - CORRECT 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 -
CORRECT ANSWER 15-25%, or 1/3 of the body blood, or 5L
clients who experience slow blood loss can - CORRECT ANSWER Tolerate the blood
loss better then a client with rapid blood loss
Signs and symptoms of compensatory shock - CORRECT ANSWER hypotension,
tachycardia, tachypnea, hypothermia, decrease pulse pressure
Questions and CORRECT Answers
What causes Autonomic Dysreflexia - CORRECT ANSWER Stimulation at level of T6 or
above
What are some examples of triggers of autonomic dysreflexia - CORRECT
ANSWER restrictive clothing; full bladder/neurogenic bladder; fecal impaction; directive
pressure s/a sitting in the wheel chair
signs and systems of Autonomic Dysreflexia - CORRECT 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 - CORRECT
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 - CORRECT
ANSWER Lactated ringers
Chemical burns should be irrigated until - CORRECT ANSWER 20 minutes or the burn
sensation continues after the 20 minute marker
what would you use to remove hot tar or asphalt - CORRECT 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 - CORRECT ANSWER cortical and premotor cortex damage
,what kind of brain injury would you expect if an adult client is positive for plantar infant reflexes
- CORRECT ANSWER upper motor neuron lesion
what kind of brain injury would you expect if an adult client is positive for rooting infant reflex -
CORRECT ANSWER frontal lobe damage
what kind of brain injury would you expect if an adult client is positive for sucking infant reflex -
CORRECT 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 - CORRECT ANSWER diffuse cortical dysfunction
What is the consensus formula for burns - CORRECT 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 -
CORRECT ANSWER Restlessness, anxiety, Hypothermia
how much fluid replacement are you going to give the first 8 hours - CORRECT
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
- CORRECT ANSWER Urine output
Besides a hyperbaric chamber how would you admin o2 to a client with CO poisoning -
CORRECT ANSWER 100% O2 with a non-rebreather
How would you treat a circumferential trunk burn that is swelling and why? - CORRECT
ANSWER Eschartomies R/T constriction of the chest wall expansion
, what are the classification of shock - CORRECT ANSWER Cardiogenic; hypovolemic,
neurogenic, and Disruptive
All shock is caused by - CORRECT ANSWER inadequate tissue perfusion
Patho of hypovolemic shock - CORRECT ANSWER Inadequate circulating blood volume
S/A burns, hemorrhage, dehydration
Patho for cardiogenic shock - CORRECT ANSWER Inadequate pumping action of the
heart S/A MI, CHF, PE
What are the 3 subclasses of Distributive shock - CORRECT ANSWER Anaphylactic;
Septic; Neurogenic
Patho for neurogenic shock - CORRECT ANSWER interference of the nervous system
that controls the blood vessels
Patho for septic shock - CORRECT 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 -
CORRECT ANSWER 15-25%, or 1/3 of the body blood, or 5L
clients who experience slow blood loss can - CORRECT ANSWER Tolerate the blood
loss better then a client with rapid blood loss
Signs and symptoms of compensatory shock - CORRECT ANSWER hypotension,
tachycardia, tachypnea, hypothermia, decrease pulse pressure
