NUR 445: Exam 3 Review (#3) UPDATED ACTUAL Questions and CORRECT
Answers
What is intracranial pressure? When pressure inside the skull dramatically increases.
- Hypoxia
- Hypercapnia
Name some factors that can increase ICP. - Hyperthermia
- TBI's
- Hemorrhage
- When was their last bowel movement
- Any noticed signs or symptoms of infection
What should the nurse ask clients with ICP?
- Any noise drainage
- How is their intake and output?
Name one of the earliest signs of ICP. Mental status change- Restless, agitated, confused.
- Double vision, swelling of the optic nerve, dilated pupils, unequal
- Positive Babinski reflex
Name five other early signs of ICP. - Decorticate or decerebrate posturing
- Seizure, headache, vomiting WITHOUT nausea
- Deterioration of motor function
An abnormal body posture that involves the arms
and legs being held straight out, the toes being
Describe decerebrate posture.
pointed downward, and the head and neck being
arched backward.
- Irregular breathing: Cheyne's stokes
What are three late signs of intracranial
- Unconscious
pressure?
- Cushing Triad: Increase in BP and decrease in HR, RR
Air enters the pleural space, disrupts negative
pressure, and causes the lung to collapse.
Describe pneumothorax.
Note: This is also known as collapsed lung.
, - Blunt force trauma: Gunshot wound, stabbing.
What are three common causes of a
- Medical procedures: Central line placement, thoracentesis.
pneumothorax?
- Mechanical ventilation: Too much PEEP
- Sudden chest pain
- Cyanosis
- Unequal chest expansion
What are six signs of pneumothorax?
- Use of accessory muscles
- Dyspnea: Low O2 and BP. High HR
- Absent breath sounds
What is the difference between open and - Open: Penetrating thoracic injury that causes air to enter from the outside in.
closed pneumothorax? - Closed: Air enters the pleural space without an outside wound.
Worsening of a pneumothorax where air
accumulates so much and cannot escape--
Describe a tension pneumothorax.
Increased intrathoracic pressure.
- Chest tube below the chest
When caring for a client was a chest tube, - Sterile water
what would you want to see in their room? - Vaseline (occlusive) gauze
- Clamps
Tension Pneumothorax: How does the Increased breathing, but the heart would have nothing to pump. Therefore, there
body try to compensate? would be an increase in HR and decrease in CO2 and BP.
Chest tube insertion.
Name one common treatment of
pneumothorax.
Tracheal deviation
What is the hallmark sign of (tension)
pneumothorax? Note: LIFE-THREATENING
- Keep the drainage system below the insertion site
What are five nursing considerations - Tubing must be free of kinks
regarding chest tubes? - Monitor lung sounds, RR, and dyspnea
- Assess for subcutaneous emphysema (crackling found on palpation of the skin)
What happens if chest tube is dislodged? Cover insertion site on 3 sides and notify MD!
Chest Tube- Water-Seal Chamber: Is No, it indicates an air leak somewhere in the system.
continuous bubbling, ok?
Chest Tube- Suction Control Chamber: Is Yes, indicates proper suction.
continuous bubbling, ok?
Chest Tube- Scenario: Within the first hour, Notify provider, as drainage should be no more than 100 mL per hour.
the client's drain showed 60 mL collection.
However, during the second hour, the
client's drain showed 220 mL collection.
How should the nurse interpret this?
- Dressing needs to be kept on for at least 2 days.
What are three teaching points for clients
- Pain is to be expected
with chest tubes removed?
- Observe and report for s/s of infection.
What is the purpose of using a ventilator? - Used for when the respiratory system is failing.
Describe positive pressure ventilation - PPV: Adding positive pressure into the airway.
(PPV).
Answers
What is intracranial pressure? When pressure inside the skull dramatically increases.
- Hypoxia
- Hypercapnia
Name some factors that can increase ICP. - Hyperthermia
- TBI's
- Hemorrhage
- When was their last bowel movement
- Any noticed signs or symptoms of infection
What should the nurse ask clients with ICP?
- Any noise drainage
- How is their intake and output?
Name one of the earliest signs of ICP. Mental status change- Restless, agitated, confused.
- Double vision, swelling of the optic nerve, dilated pupils, unequal
- Positive Babinski reflex
Name five other early signs of ICP. - Decorticate or decerebrate posturing
- Seizure, headache, vomiting WITHOUT nausea
- Deterioration of motor function
An abnormal body posture that involves the arms
and legs being held straight out, the toes being
Describe decerebrate posture.
pointed downward, and the head and neck being
arched backward.
- Irregular breathing: Cheyne's stokes
What are three late signs of intracranial
- Unconscious
pressure?
- Cushing Triad: Increase in BP and decrease in HR, RR
Air enters the pleural space, disrupts negative
pressure, and causes the lung to collapse.
Describe pneumothorax.
Note: This is also known as collapsed lung.
, - Blunt force trauma: Gunshot wound, stabbing.
What are three common causes of a
- Medical procedures: Central line placement, thoracentesis.
pneumothorax?
- Mechanical ventilation: Too much PEEP
- Sudden chest pain
- Cyanosis
- Unequal chest expansion
What are six signs of pneumothorax?
- Use of accessory muscles
- Dyspnea: Low O2 and BP. High HR
- Absent breath sounds
What is the difference between open and - Open: Penetrating thoracic injury that causes air to enter from the outside in.
closed pneumothorax? - Closed: Air enters the pleural space without an outside wound.
Worsening of a pneumothorax where air
accumulates so much and cannot escape--
Describe a tension pneumothorax.
Increased intrathoracic pressure.
- Chest tube below the chest
When caring for a client was a chest tube, - Sterile water
what would you want to see in their room? - Vaseline (occlusive) gauze
- Clamps
Tension Pneumothorax: How does the Increased breathing, but the heart would have nothing to pump. Therefore, there
body try to compensate? would be an increase in HR and decrease in CO2 and BP.
Chest tube insertion.
Name one common treatment of
pneumothorax.
Tracheal deviation
What is the hallmark sign of (tension)
pneumothorax? Note: LIFE-THREATENING
- Keep the drainage system below the insertion site
What are five nursing considerations - Tubing must be free of kinks
regarding chest tubes? - Monitor lung sounds, RR, and dyspnea
- Assess for subcutaneous emphysema (crackling found on palpation of the skin)
What happens if chest tube is dislodged? Cover insertion site on 3 sides and notify MD!
Chest Tube- Water-Seal Chamber: Is No, it indicates an air leak somewhere in the system.
continuous bubbling, ok?
Chest Tube- Suction Control Chamber: Is Yes, indicates proper suction.
continuous bubbling, ok?
Chest Tube- Scenario: Within the first hour, Notify provider, as drainage should be no more than 100 mL per hour.
the client's drain showed 60 mL collection.
However, during the second hour, the
client's drain showed 220 mL collection.
How should the nurse interpret this?
- Dressing needs to be kept on for at least 2 days.
What are three teaching points for clients
- Pain is to be expected
with chest tubes removed?
- Observe and report for s/s of infection.
What is the purpose of using a ventilator? - Used for when the respiratory system is failing.
Describe positive pressure ventilation - PPV: Adding positive pressure into the airway.
(PPV).
