NUR 2755 Multidimensional Care IV- MDC 4 - Rasmussen College FINAL EXAM (7 Combined Exam Sets)

NUR 2755 FINAL EXAM 7 EXAMS SET COMBINED Latest 2023 COMPLETE SOLUTION Multidimensional Care IV MDC 4 Rasmussen College NUR 2755 FINAL EXAM 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 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? 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 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 - 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 drop Pt'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 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 - 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 - Airway Give instructions/education to a pt going to receive and EEG, can they have anything with caffeine? - NO caffeine Rasmussen College : NUR 2755/ MDC4 FINAL EXAM 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 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 drop Pt'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 NUR 2755 Multidimensional Care IV Why teach patient to deep breath and cough after surgery - prevent pneumonia Gave double dose of medication, what to do first? - Assess patient What to do when patient comes back from surgery, and they're declining (rapid, shallowrespirations, elevated heart rate, blood pressure dropping), what do you do?? - Call rapid response team Allergy exposure situation - more exposure to allergen the more risk to developing a reaction Patient in lithotomy position for surgery, where would their experience post op discomfort?? - Shoulders Why do we have drainage tubes/what's the purpose?? - To help prevent infection Why do we give a patient with multiple sclerosis Baclofen?? - To treat muscle spasms Patient has head to toe trauma and at risk for developing ARDS, what is the earliest sign? - Increased respiratory rate What is the most common first symptom with a patient with a PE? - Chest pain Pain response in an unconscious patient? (peripheral pain response) - Squeezing the nail beds What are measures for a patient with a head injury, how do we prevent increase intracranialpressure? - Decrease stimulusSlow movements Don't cough hard or blow noseDeep Breaths Slow exhale to help with pain control Patient has clear fluid coming from nose, what tests would we do or see? - Positive for glucose Yellow halo on white linen or filter paper Patient with spinal cord injury, how to lessen change of AD? - Bowel/Bladder Program Patient with Parkinson's, when should you schedule their most demanding activities??? - When the drug therapy/medication peaks for them. Normal drainage for surgical site? - Clear (serous) or pale/red/watery (serosanguineous) Worrisome sign of post op patient?? - Restlessness Community disaster preparedness, what would be an organization to help? - *Medical Reserve Corporation* FEMA Red Cross DMAT?? - Disaster Medical Assistance TeamFederal employees License is good in ALL 50 states How many days of medical supplies should you have if needed for a disaster, just making adisaster plan? - 3 days Cimetidine for burn patients?? Why?? - Help with gastric ulcers - Nam Age Inju ry (Anything to help identify)Any treatments we did Who we can contact/who has been contacted.Triage colors Somebody that has a thrombotic stroke, what is important assessment item, especially in thefirst 24 hours?? - Pupil response to light/size Someone had an ischemic stroke and getting thrombolytic treatment, what are we trying tocontrol in the first 24 hours?? - Blood pressure How to determine if patient can have tPA after stroke AFTER CT?? - Onset of symptoms within 3 hours. effect, but we wouldn't stop the medication? (Expected side effect) - Excessive gum tissue growth *DO NOT STOP MEDICATION SUDDENLY* What would be a potential finding in postical phase of a generalized tonic clonic seizure whatwe would want to monitor for?? - Drowsiness Priority intervention in postical phase of tonic clonic seizure?? - Airway - assess breathing pattern Prep for an EEG?? They know they'll have one in the morning, so what prep do they need to door not do beforehand?? - Can eat NO Caffeine What do you expect to see in a patient in ictal phase of generalized tonic clonic seizure?? - Jerkin g Stiffne ss Loss of consciousness Loss of bowel/bladder What to do when someone is coming out of a coma - had head injury and they're starting towake up now after a few days what would we want to do??? - Orient them Decerebrate assessment - rigid arms, wrists/hands c shaped & flexed outwardpossible arched back Patient is getting IV heparin for a PE, what would PTT be at for therapeutic levels?? - Higher --> like if its at 25, we would want to increase the rate of heparin Gene Alteration CYP2C19 and history of PE, what to do to prevent further issues? - IVCF - Inferior Vena Cava Filter Mean Arterial Pressure, how to correlate with blood loss?? - Lower blood volume = lower MAP How to calculate MAP?? - Double the bottom number of blood pressure, add that to the top number and thendivide by 3. Example: BP is 120/80,80+80 = 160 160 + 120 = 280 280/3= 93.333 MAP would be 93. What to educate elderly patients on about rehydration to prevent shock?? - Increase fluids, drink on a regular schedule What lab value will be off in a patient with shock, septic shock? - Lactic Acid What to remember when determining triage or prioritization of patients?? - ABCs Sick calls and tension with staff after a long week of critical care patients, what is important toremember in this aspect>> - Debriefing External disaster examples - Tornad o Floodin g Hurrica ne When we see a patient passed out/unconscious at home, with cherry red skin color, what do we assume??? - Carbon monoxide poisoning Make sure that if a patient we did Parkland Formula, and still low urine output, what else canwe do?? - Increase fluid rate Monitor urine output Check electrolytes Parkland formula - 4 mL x TBSA (%) x body weight (kg). 50% given in first 8 hours, 50% given over the next16 hours. Patient with a burn, what electrolyte would we typically initially see with 3rd spacing of fluid?? - High potassium What patient would be at high risk for developing a PE?? - Hx of DVT Smokin g Oral birth control Pregnancy Immobility Major long bone fractureHx of falls Post Op patients How would you determine if patient is receiving good ventilation?? - Equal chest riseStable vitals Skin color Capillary Refill What type of alarm would you hear if patient has mucous plug and needs suctioning?? - High pressure alarm initial phase of shock - MAP decreased by 10 mmHg from baseline. Mild vasoconstriction. Increased heart rate. Vital organ function is NOT disrupted. Indicators of shock are difficult to detect atthis stage. THIS STAGE IS STILL REVERSIBLE. Nonprogressive phase of shock - MAP decreases by 10-15 mmHg from baseline. Moderate vasoconstriction. Increasedheart rate and decreased pulse pressure. Chemical compensation. Decreased urine output, stimulation of thirst reflex, mild acidosis, mild hyperkalemia. Tissue hypoxia occurs in nonvital organs and in the kidneys but is not great enough to cause permanent damage. Restlessness, tachycardia, increased respiratory rate, falling systolic blood pressure, narrowing pulse pressure, cool extremities, and a 2%- 5% change in oxygen saturation. THIS STAGE IS STILL REVERSIBLE. Progressive phase of shock - Decrease of more than 20% MAP. Anoxia of nonvital organs, hypoxia of vital organs.Moderate acidosis, moderate hyperkalemia, tissue ischemia. Some tissues die. Patientmay have a sense of impending doom or "something bad". Patient may become confused and thirst increases. Rapid weak pulse, low blood pressure, pallor to cyanosis of oral mucosa and nail beds, cool and moist skin, anuria, and 5%-20% decrease in oxygen saturation. - FINAL PHASE Final stage and also irreversible stage. Occurs when too much cell death and tissuedamage has happened. Vital organs have extensive damage and cannot respond effectively to interventions, so shock continues. Severe tissue hypoxia with ischemiaand necrosis. Buildup of toxic metabolites. MODS. Death. Clearly if patient is presenting to ER with heat exhaustion, what is the priority action of thenurse? - IV Fluids Action is patient has bee sting. . if available? - Epi When patient presents to ER with suspicion of sepsis, what to do in the first few hours?? - Lactic acid Blood cultures Antibiotics AFTER blood cultures - A&P head: each 4.5% (9% entire head)A&P chest: 18% each A&P arm: 4.5% each side on each arm (9% entire each arm)A&P leg: 9% each side, each leg. (18% entire each leg) Groin: 1% Deep partial thickness burns - Red to white Moderate EdemaYes pain Blisters are rate Yes eschar (its soft and dry)Healing time is 2-6 weeks Grafts can be used in prolonged healing time What happens to a patient that has drowned? - Large influx of patientsExample: explosion Wellness for nurses to prevent burn out and PTSD - Counseling Encourage & Support coworkers Monitor each other's stress levelsTake breaks when needed Talk about feelings Drink plenty of water Healthy snacks for energy Keep in touch with family, friends and SODo not work more than 12 hours How do we treat frostbite? What are some concerns with frostbite? - Edema and swelling --> elevation above level of heart. Patient has overheated, hot to touch, flushed face and passed out at a sporting event. (Heat Stroke). What do we do? - Get out of the sun, hydration (sips), cool them down - get clothes wet. The priority isto get them out of the sun and into the shade and cool them down! With overheating/heat stroke, do we want to cause shivering?? Why or why not? - No! Shivering is the body's was of warming the body. What other symptoms (objective findings) would you see in a patient that overheated/heatstroke? - Sweating lightheaded/dizzy confusion/hallucina tions elevated heart rate (could be irregular)elevated blood pressure decreased urine output Come upon a car crash with multiple victims, what is priority/what patient is at biggest risk? - Airway/breathing issue first Term for initial surveillance of injury - triage How to teach CNA easiest way to cool down a patient? - Remove clothing & blankets Frost bite 2nd degree - large clear-to-milky fluid filled blisters develop with partial thickness skin necrosis. *Redness and blisters filled with fluid* In a patient with hypothermia what are we concerned about with the heart? and why do wemonitor the heart? - To watch for serious arrhythmias What causes serious arrhythmias in patients with hypothermia?? - Blood pooling in the extremities, blood is shunted from getting to the heart.Therefore, lactic acid lab will be abnormal. This will cause the arrhythmias. What will we HEAR with a pneumothorax? Expected finding - Diminished breath sounds What do you see with a flail chest? The most distinctive sign?? - Paradoxical chest movements What is the initial reaction for a low-pressure alarm, what would you check first?? - low pressure alarm = not getting enough oxygen. Bag the patient manually. High pressure alarm, absent breath sounds in right upper chestwhat is it likely to be?? - Pneumothorax How to know if spinal shock is still continuing in a spinal cord injury patient? - Absent/decreased reflexes **Protect the head! Patient is having a seizure, what would you do? - Left side Lay flat loosen clothing padded side rails protect head suction at bedside SAFETY! Patient had a stroke and having homonymous hemianopsia after, how do we help them? - Check all fields (turn head side to side) Myasthenia Gravis: how do we prevent chlorogenic crisis? - Medication regimen Parkinson's: how to help maintain mobility?? - encourage mobility Bradykinesia (Slow Movement) - rocking back and forth to get up helps with this Gillian Barre Syndrome: what would be something that could have happened in the recent history that you would want to ask that happened?? - Infections/Virus in the last month What can you do for a Gillian Barre Syndrome patient?? - Active listening Support System Encourage/Positive Feedback How does paralysis occur with Gillian Barre Syndrome?? - Ascendin g (bottom up) First signs of meningitis? - Positive Kernig sign Positive Nuchal rigidity Positive Brudzinski sign Halo device: should a patient drive? - NO- patient should NOT drive NUR2755 / NUR 2755 FINAL EXAM Multidimensional Care IV /MDC 4 - Rasmussen NUR 2755 Multidimensional Care IV what are the treatments for frostbite in the ED? - Warm saline, immerse hands/feet in warm water, elevate affected limbs, have themrub their hands together Priority treatment for pt with a heat stroke - Move them out of the sun, into shade First priority assessment - Airway Pt with a head injury & are arousable, what is one intervention the pt can do themselves toreduce 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 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 couldhave 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 lowerlobe. 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 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/ thisillness? - 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 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 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 drop Pt'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 numeroustraumas, what is the first action? - Debriefing Pt is found unresponsive in their home & their skin is bright cherry red. What do you suspecthappened? What lab to get? - Carbon monoxide poisoning; carboxyhemoglobin Alzheimer's Mild Stage (answer) -Forgets names; misplaces household items -Has short-term memory loss and difficulty recalling new information -Shows subtle changes in personality and behavior;Alzheimer's Moderate Stage (answer) -Is disoriented to time, place, and event -Has difficulty driving and gets lost -Incontinent -Psychotic behaviors, such as delusions, hallucinations, and paranoia -Episodes of wandering, trouble sleeping;Alzheimer's Late Stage (answer) -Totally incapacitated; bedridden -Totally dependent in ADLs -Has agnosia -Hallucinations -Incontinence -Difficulty eating;Apraxia (answer) Difficulty with motor planning to perform tasks or movements;Aphasia (answer) Inability to speak or understand language;Anomia (answer) Inabilityto recall the names of everyday objects;Agnosia (answer) Loss of sensory comprehension, including facial recognition;Alzheimer's diagnostics (answer) -No laboratory test can confirm the diagnosis of AD -Definitive diagnosis is made on the basis of brain tissue examination at autopsy, which confirms the presence of neurofibrillary tangles and neuritic plaques;Alzheimer's medications (answer) Cholinesterase inhibitors- Donepezil, galantamine NMDA receptor antagonists- Memantine;Parkinson's symptoms (answer) -Slow, shuffling, and propulsive gait -RESTING tremors -Muscle rigidity -Bradykinesia/akinesia (loss of ability to move muscles voluntarily) -Mask Like face -Drooling -Postural instability;Parkinson's diagnostics (answer) -Diagnosis typically made based on manifestations, their progression, and by ruling out other disease -Analysis of CSF may show a decrease in dopamine levels;Parkinson's medications (answer) Carbidopa/Levodopa (Sinemet);Parkinson's surgical interventions (answer) Stereotactic pallidotomy or thalamotomy;Migraine triggers (answer) -Caffeine -Red wine -MSG -Foods high in tyramine (aged cheeses, cultured food like yogurt);Migraine abortive therapy (answer) Acetaminophen, ibuprofen, naproxen, triptans, ergotamine derivatives;Migraine preventative therapy (answer) Beta blockers, calcium channel blockers, antiepileptics, Botox;Migraine surgical treatment (answer) Trigeminal nerve resection;Aura symptoms (answer) -Visual disturbances -Flashing lights/lines/spots -Numbness of lips or tongue -Acute confused state -Aphasia -Vertigo -Unilateral weakness* -Offensive smell -"Deja vu" feeling;Multiple sclerosis clinical manifestations (answer) -Muscle weakness and spasticity -Intention tremors (tremor when performing an activity) -Diplopia (double vision) -Nystagmus (an involuntary condition in which the eyes make repetitive uncontrolled movements) -Depression/labile;Multiple sclerosis diagnosis (answer) MRI of the brain and spinal cord demonstrates the presence of plaques in at least 2 areas;Multiple sclerosis medications (answer) - Baclofen -Disease-modifying therapies -Interferon beta-1a and beta-1b -Corticosteroids;Meningitis clinical manifestations (answer) -Nuchal rigidity -Kernig Sign -Brudzinski Sign -Decreased level of consciousness -Photosensitivity;Kernig Sign (answer) Resistance and pain with extension of the client's leg from a flexed position;Brudzinski Sign (answer) Flexion of the knees and hips occurring with deliberate flexion of the client's neck;Meningitis diagnostics (answer) Lumbar puncture Appearance of CSF: cloudy(bacterial) or clear (viral);Preventionof meningitis (answer) Meningococcal vaccine;Droplet precautions (answer) -Private room -Stay at least 3 feet away from the patient unless wearing a mask -Patients who are transported outside the room should wear a mask -Health care personnel should wear gloves, gown, and mask;Tonic-clonic seizure (answer) Generalized seizure in which the patient loses consciousness and has both stiffening of the muscles (tonic) and rhythmic jerking of the extremities (clonic);Tonic seizure (answer) Clients suddenly lose consciousness and experience sudden increased muscle tone, loss of consciousness, and have autonomic manifestations;Clonic seizure (answer) Only the clonic phase is experienced (rhythmic jerking of the extremities);Myoclonic seizure (answer) Lasting only seconds, myoclonic seizures consist of brief jerking or stiffening of the extremities, which can be symmetrical or asymmetrical;Atonic or akinetic seizure (answer) Characterized by a few seconds in which muscle tone is lost;Complex partial seizure (answer) -Seizures associated with automatisms (behaviors that the client is unaware of, such as lip smacking or picking at clothes) -Can cause loss of consciousness;Simple partial seizure (answer) Seizure where consciousness is maintained;Seizure diagnostics (answer) -Electroencephalogram (EEG) -CT/MRI;Seizure interventions (answer) -Turn the patient on their side -Remove objects that may injure the patient -Suction as needed -Oxygen -Padded side rails -IV access (saline lock) -Bed in lowest position -Nothing in mouth -Loosen or remove restrictive clothing;Seizure medications (answer) -Lorazepam or diazepam IV push to stop a seizure (4 mg over a 2 minute period) -Phenytoin (therapeutic range 10 to 20 mcg/ml);Earliest sign of increased intracranial pressure (answer) Decreased level of consciousness;Increased intracranial pressure early signs (answer) - EARLIEST SIGN: Decreased level of consciousness -Restlessness -Changes in speech -Confusion -Headache -Nausea and vomiting → projectile;Increased intracranial pressure late signs (answer) -Pupillary changes → can mean herniation -Cranial nerve dysfunction -Ataxia -Cushing's triad (very late sign);Increased intracranial pressure interventions (answer) -Low stimulation -Semi-fowlers → 30 degrees -Head in neutral position -Do not cluster activities -Suction only as needed -Teach patient not to cough or blow their nose -Dim lighting -Stool softeners -Do not bend or bare down;Increased intracranial pressure treatment (answer) IV mannitol given through a filter because it crystallizes at room temperature;Cushing's triad (answer) Severe hypertension, widened pulse pressure (difference between the systolic and diastolic bloodpressure), bradycardia, irregular respirations;Pulse pressure (answer) Difference between systolic and diastolic pressure;Ischemic stroke (answer) Caused by the occlusion of a cerebral artery by either a thrombus or an embolus.;Thrombotic stroke (answer) Occur secondary to the development of a blood clot on an atherosclerotic plaque in a cerebral artery that gradually shuts off the artery and causes ischemia distal to the occlusion;Embolic stroke (answer) Caused by an embolus traveling from another part of the body to a cerebral artery. Blood to the brain distal to the occlusion is immediately shut off causing neurologic deficits or a loss of consciousness to instantly occur.;Hemorrhagic stroke (answer) Occur secondary to a ruptured artery or aneurysm. The prognosis for a client who has experienced a hemorrhagic stroke is poor due to the amount of ischemia and increased ICP caused by the expanding collection of blood. Patients will complainof the "worst headache of my life".;Alexia (answer) Inability to understand written words;Stroke diagnostics (answer) A non-contrast computed tomography (CT) scan (WITHOUT CONTRAST) is the initial diagnostic test and should be performed within 25 minutes from the time of client arrival to the emergency department;Homonymoushemianopsia interventions (answer) -Instruct them to use a scanning technique (turning head from the direction of the unaffected side to the affected side) when eating and ambulating -Rotate their plate so that they can see it -Talk to them on their good side;Ischemic stroke treatment (answer) -Give thrombolytics within 4.5 hours of initial manifestations -Low-dose aspirin is given within 24-48 hours following an ischemic stroke to prevent further clot formation;Stroke prevention (answer) -Smoking cessation -Heart-healthydiet rich in fruits and vegetables and low in saturated fats -Regular activity, including planned exercise; example: walking at least 30 minutes most days of the week -Reduction in alcohol consumption -Reduction of salt in diet;Post-stroke feeding interventions (answer) -An RN should provide the initial feeding and intervene if choking occurs. Some clients require an eating environment without distractions to prevent choking. -Chin tuck when swallowing -Watch for pocketing -Put food on the unaffected side -Aid cannot feed unless they are stable -Do not rush the patient while they are eating;Decorticate posturing (answer) Hands towards the CORE;Decerebrate posturing (answer) Hands OUT ("to celebrate");ICP can be increased by (answer) - Hypercarbia, which leads to cerebral vasodilation -Endotracheal or oral tracheal suctioning -Coughing -Extreme neck or hip flexion/extension -HOB at less than 30 degrees -Increasing intra-abdominal pressure (restrictive clothing, Valsalva maneuver);Ways to decrease ICP (answer) -Elevate HOB to at least 30 degrees -Maintain patent airway -Administer oxygen to maintain PAO2 greater than 60 mmHg -Limit visitors, minimize noise;Brain death diagnosis prerequisites (answer) -Coma of known cause as established by history, clinical examination, laboratory testing, and neuroimaging -Normal or near-normal core body temperature (higher than 96.8°F (36°C) -Normal systolic blood pressure (higher than or equal to 100 mm Hg) -At least one neurologic examination (many U.S. states and health care systems require two);Spinal shock (answer) Physiologic response that occurs between 30 and 60 minutes after trauma to the spinal cord and can last up to several weeks. Spinal shock presents with total flaccidparalysis and loss of all reflexes below the level of injury. Paralytic ileus can also occur.;Autonomic dysreflexia clinical manifestations (answer) -Sudden, significantrise in systolic and diastolic blood pressure, accompanied by bradycardia -Headache -High temperature -Profuse sweating/flushing (redness) above the level of the lesion -Pale skin below the level of the lesion -Blurred vision -Nasal congestion;Autonomic dysreflexia interventions (answer) -Sit the client up (90 degrees) to decrease blood pressure secondary to postural hypotension (first priority!) -Determine and treat the cause (kinked cath, fecal impaction, restrictive clothing) -Administer antihypertensives (nitrates or hydralazine);Myasthenia gravis pathophysiology (answer) Acquired autoimmune disease characterized by muscle weakness that is proximal to distal;Myasthenia gravis clinical manifestations (answer) -Progressive (proximal to distal) muscle weakness that worsens with repetitive use and usually improves with rest -Ptosis (incomplete eyelid closure) -Diplopia -Respiratory compromise -Incontinence -Fatigue;Myasthenia gravis treatment (answer) Cholinesterase (ChE) inhibitor drugs are the first-line management of MG. Ex: pyridostigmine.;Cholinergic crisis (answer) -The patient has received too much cholinesterase inhibitor drug -Muscle tone DOES NOT improve after giving Tensilon -Give atropine;Myasthenic crisis (answer) -The patient has received too little cholinesterase inhibitor drug -Muscle tone DOES improve after giving Tensilon;Gullian-Barre Syndrome clinical manifestations (answer) -Ascending symmetric muscle weakness (legs and up) -Decreased or absent deep tendon reflexes -Respiratory compromise -Ataxia -Dysphagia -Diplopia;Gullian-Barre causes (answer) -Often associated with bacterial infection, especially with Campylobacter jejuni. Influenza, Epstein-Barr, and cytomegalovirus (CMG) viral infections have also been associated with GBS -Zika Virus -Vaccines -Autoimmune response;Gullian-Barre treatment (answer) -Plasmapheresis (Removes the circulating antibodies thought to be responsible for the disease) -IV immunoglobulin (Reduces production of antibodies);Bell's Palsy clinical manifestations (answer) -RULE OUT STROKE FIRST -Most severe at 48 hours -The patient cannot lose his or her eye, wrinkle the forehead, smile, whistle, or grimace -Tearing may stop or become excessive -Taste is usually impaired to some degree -Tinnitus;Bell's Palsy treatment (answer) -Corticosteroids 30-60 mg daily for the first few days -Antiviral drugs -Eye drops due to eyes not closing properly;Implied consent (answer) Type of consent in which a patient who is unable to give consent is given treatment under the legal assumption that he or she would want treatment.;Informed consent (answer) Nurse's responsibilities: Witness informed consent -Ensure that the provider gave the client the necessary information -Ensure that the client understood the information and is competent to give informed consent -Notify the provider if the client has more questions or appears to not understand any of the information provided -Have the client sign the informed consent document;Informed consent and minors (answer) Only MARRIED or EMANCIPATED minors can give informed consent;Pre-op labs (answer) -Urinalysis -Blood type and crossmatch -CBC or hemoglobin level and hematocrit -Clotting studies (PT, INR, aPTT) -Electrolyte levels (especially potassium) -Serum creatinine level -Pregnancy test;NPO before surgery (answer) -Ensure that the patient remains NPO for at least 6 hours for solid foods and 2 hours for clear liquids before surgery with general anesthesia to avoid aspiration -Note on the chart the last time the client ate or drank;Surgery: prophylactic antibiotics (answer) Prophylactic antibiotics are administered within 1 hour of surgical incision;Latex allergies: Also check for allergies to (answer) -Shellfish -Eggs/peanuts/soy → may interfere with propofol -Avocados -Bananas -Kiwi -Strawberries -Check if they've had over-exposure to latex; this can create an allergy;Circulator RN (answer) NOT STERILE -Initiates the TIME OUT procedure -Sets up OR, gather supplies, inspects equipment, monitor asepsis -Monitors room traffic in and out of room;Scrub RN (answer) STERILE -Sponge count -In charge of sterile field;Malignant hyperthermia symptoms (answer) -High body temperature -Muscle rigidity of the jaw and upper chest -Tachycardia -Tachypnea -Hypotension -Cyanosis;Malignant hyperthermia treatment (answer) Dantrolene;Dehiscence (answer) Bursting open of a wound, especially a surgical abdominal wound. If dehiscence (wound opening) occurs, apply a sterile non adherent or saline dressing to the wound and notify the surgeon.;Evisceration (answer) MEDICAL EMERGENCY -Call for another nurse to notify the surgeon and/or Rapid Response Team (RRT) -Stay with the patient -Place the patient in a supine position with the hips and knees bent. -Raise the head of the bed 15 to 20 degrees. -Place dressings moistened with sterile saline over the exposed viscera. -Do not attempt to reinsert the protruding organ or viscera.;DVT/PE prevention(answer) Compression stockings Ambulate ASAP Ted hose Enoxaparin;Wound infection symptoms (answer) -Redness/erythema -Oozing → purulent and smelly drainage -Warm to the touch -Swollen, hard skin -Severe pain;Atelectasis (answer) Collapsed lung; incomplete expansion of alveoli. Can happen after surgery as a result of anesthesia;Superficial burns (1st degree) (answer) -Damage to the epidermis -Dry, pink to red -NO edema, blistering, or eschar -Painful -Healing time is about 1 week;Superficial partial-thickness burns (2nd degree) (answer) -Damage extends into the dermis -Moist, red, blanching, blistering -Mild to moderate edema -Blisters -Extensive pain -NO eschar -Healing time about 2 weeks;Deep partial-thickness burns (2nd degree) (answer) -Epidermis and into the dermis, can vary in depth -Less moist, less blanching, less painful -Moderate edema -Blisters rare -Some pain -Soft and dry eschar -Healing time about 2-4 weeks;Full-thickness burns (3rd degree) (answer) -Entire thickness of skin destroyed, into subcutaneous tissue -Black, red, yellow, brown, white -Severe edema -NO blisters -NO pain -Eschar hard and inelastic -Healing time weeks to months;Deep full-thickness burns (4th degree) (answer) -Damage extends into muscle, tendon, bone -Black -Severe edema -NO blisters -NO pain -Eschar -Healing time weeks to months, if at all;Resuscitation phase labs (answer) -Increased glucose -Increased BUN -Increased Ht and Hgb -Decreased sodium -Increased potassium -Increased chloride -Increased CO2 (More than 10% strongly indicates smoke inhalation) -Decreased protein -Decreased albumin (Normal range 3.4 - 5.4 g/dl) -Metabolic acidosis;Fluid remobilization labs (answer) -Decreased Hgb and Hct -Decreased sodium -Decreased potassium -Increased and then decreased WBC -Increased glucose -Decreased protein -Decreased albumin;Minor burns interventions (answer) -Cleanse with mild soap and tepid water -Use antimicrobial agent -Avoid greasy lotions or butter on the burn -Determine need for tetanus immunization;Burns expected manifestations during the initial phase (answer) -Tachycardia -Increased RR -Decreased GI motility -Increased glucose;Fluid of choice for burn fluid resuscitation (answer) Lactated ringers is fluid of choice, can also infuse 0.9% sodium chloride;General burns interventions (answer) -Provide humidified oxygen -A tracheotomy when long-term intubation is expected -Suction every hour as needed -Initiate IV access using a large-bore needle -Use IV route for medications -Keep pt's room warm -Restrict plants and flowers -Limit visitors -Use strict asepsis with wound care -Large burn areas crease a hypermetabolic state, requiring 5000 calories/day -Facilitate position changes to prevent contractures -Assist with ambulation as soon as the client is stable;Burn compression stockings (answer) Wear compression dressings as prescribed (usually 23 hours a day) to minimize scarring and prevent difficulty with mobility;Fluid overload signs and symptoms (answer) -Hypertension -Edema -Engorged or distended neck veins -Rapid and thready pulse -Lung crackles wheezes;Burns Emergent/Resuscitative Stage (answer) Onset to 24-48 hours ABC Securing the airways Supporting circulation and perfusion (escharotomy) Maintaining body temperature Pain management Emotional support Start large bore IV and begin parkland method Administer tetanus Give albumin;Burns Acute Phase (answer) 36-48 hours Begins when the fluid shift resolves and ends when the wound closure is complete -Diuresis or a large amount of clear/yellowurine is the best way to determine they are in this phase -Pain control -Burn wound care (debridement/skin grafting) -Psychosocial interventions Nursing interventions: -Protein, vitamin C & E -NEUTRAL position with minimal flexion -ROM 3x per day, with consideration of splints -AMBULATE patient ASAP if they are able to walk;Burns Rehabilitative Phase (answer) Begins with wound closure and ends when the patient reaches the highest level of functioning Emphasis on psychosocial adjustment of the patient, prevention of scars and contractures, and the resumption of preburn activity;Rule of Nines (answer) A system that assigns percentages to sections of the body, allowing calculation of the amount of skin surface involved in the burn area.;Parkland formula (answer) 4mL x kg x %TBSA = XXXXmL Then give 1st ½ over 8 hours → This starts at the time of the injury, not when they arrive to the hospital Then 2nd half over the following 16 hours;Urine output (answer) Urine output should be at least 30 mL per hour 0.5 mL x kg = mL per hour;Carbon monoxide poisoning clinical manifestaions (answer) -"Cherry-red" color of skin (erythema) -Headache -Normal O2 saturation -Weakness -Dizziness -Confusion -Upper airway edema;Carbon monoxide treatment (answer) Hyperbaric chamber with 100% oxygen;Burn shock manifestations (answer) -Confusion -Increased cap refill time -Urine output less than 30 mL/hr -Rapid elevations of temperature -Decreased bowel sounds -BP average or low;Curling ulcers (answer) Pathophysiology -Acute gastroduodenal ulcer that occurs with the stress of a severe injury -May develop within 24 hours after a severe burn injury Treatment -H2 histamine blockers -Proton pump inhibitors -Drugs that protect GI tissues -Early enteral feeding;Signs of an inhalation injujry (answer) Effects may not manifest for 24 to 48 hours -Facial burns -Singed hair, eyebrows, and/or eyelashes -Black carbon particles in the nose, mouth, and sputum and edema of the nasal septum -Smoky smell to the breath -Change in respiratory pattern -Drooling -Dysphagia;Inhalation injury treatment (answer) -Place the client upright -High-flow oxygen -Possible intubation;ARDS causes (answer) Shock Trauma PE Sepsis Aspiration Multiple blood transfusions Drowning Pneumonia Pancreatitis;ARDS clinical manifestations (answer) -Dyspnea -Bilateral noncardiogenic pulmonary edema (diffuse crackles heard upon auscultation) -Non-cardiac pulmonary edema -Ground-glass appearance -Reduced surfactant resulting in reduced lung compliance -Dense, patchy bilateral pulmonary infiltrates -Refractory hypoxemia -Fast RR rate;ARDS interventions (answer) Intubation with PEEP and PRONE positioning Have suction equipment and ambu bag at the bedside;Early signs of hypoxemia (answer) Restlessness/irritability Tachypnea Tachycardia Pale skin Increased BP Nasal flaring/ use of accessory muscles;Late signs of hypoxemia (answer) Confusion Stupor Cyanosis Bradypnea Bradycardia Hypotension;Pulmonary embolism clinical manifestations (answer) -Tachycardia -Increased respiratory rate -Hypotension -Crackles -Sudden onset of dyspnea -Sharp, stabbing chest pain -Shortness of breath -Apprehension, restlessness -Cough/bloody sputum -Tachycardia -Petechiae over chest and axillae;Pulmonary embolism risk factors (answer) -Prolonged immobility -Central venous catheters -Smoking -Birth control/estrogen -Musculoskeletal injuries (spinal cord) -Atrial fibrillation!!! -Surgery -Pregnancy -Obesity -Advancing age -Conditions that increase blood clotting -History of PE/DVT;Pulmonary embolism diagnostics (answer) -Computed tomography pulmonary angiography (CTPA) -Helical CT -Elevated D-Dimer (Normal <0.4 mcg/mL);Pulmonary embolism treatment (answer) ANTICOAGULANTS Heparin (monitor PTT/aPTT) Warfarin (monitor PT and INR) During transition period between heparin and warfarin, monitor aPTT, INR, and platelet count;Pulmonary embolism surgical management (answer) Embolectomy The surgical or percutaneous removal of the embolus IVC filtration (filter) With placement of a retrievable vena cava filter prevents further emboli from reaching the lungs in patient with ongoing riskfor PE;Pulmonary edema clinical manifestations (answer) Pink frothysputum Coarse crackles Low pitched crackles;Pulmonary edema teaching (answer) -Take meds and finish them -Monitor for swelling of the face or SOB -Daily weights and notify if you gain more than 2lb/day or 5lb/week -LOW sodium diet;Early signs of pneumonia (answer) Purulent sputum Diminished lung sounds Fatigue Cough;Late signs of pneumonia (answer) Chest pain Dyspnea Tachycardia Activity intolerance Respiratory distress;Flail chest clinical manifestations (answer) -KEY SYMPTOM: Paradoxical chest movement/respirations Pattern of breathing in which the chest wall contracts during inspiration and expands with expiration -Dyspnea -Cyanosis -Tachycardia -Hypotension -The patient is often anxious, short of breath, and in pain;Flail chest treatment (answer) -Intubate! -Usually stabilized with positive-pressure ventilation;Tension pneumothorax (answer) Life- threatening complication of pneumothorax in which air continues to enter the pleural space during inspiration and does not exit during expiration. As a result, air collects under pressure, completelycollapsingthe lung and compressing blood vessels, which limits blood return. This process leads to decreased filling of the heart and reduced cardiac output.;Pneumothorax clinical manifestations (answer) -KEY SYMPTOM: When severe, deviation of the trachea toward the unaffected side -Reduced chest movement on the affected side -Reduced (or absent) breath sounds of the affected side;Tension pneumothorax clinical manifestations (answer) -Distended neck veins -Tracheal deviation to the unaffected side -Extreme respiratory distress and cyanosis -Hemodynamic instability;Hemothorax clinical manifestations (answer) Percussion on the involved side produces a dull sound;Pneumothorax treatment (answer) Chest tube;Tension pneumothorax treatment (answer) Immediate needle thoracostomy;Hemothorax treatment (answer) -Thoracentesis -Chest tube;Thoracentesis position (answer) Sitting on the side of the bed and leaning over the table (during procedure); Affected side up (after procedure);Chest tube tidaling (answer) Fluid will go up and down with respiratory effort (in water seal chamber);Chest tube bubbling (answer) -Okay to have occasional bubbles in water seal chamber on initial insertion (means air is leaving) -Continuous bubbling in the water seal chamber means there is a leak;Chest tube suction chamber (answer) -Controls amount of suction in the client's cavity -Constant bubbling here is NORMAL;Tracheostomyindication(answer) -A tracheostomy is considered if an artificial airway is needed for longer than 10 to 14 days in order to reduce tracheal and vocal cord damage -Tracheostomy is also considered when a patient requires more than one intubation for respiratory failure;Endotracheal tube placement (answer) ET tube marking should be at the client's incisor;The nurse is trouble-shooting multiple ventilator alarms sounding for a client who is intubated and being mechanically ventilated. The alarms persist despite suctioning, repositioning the client, and ensuring that the ventilator tubing is unobstructed. Which actions will the nurse perform next? (answer) - Ensure the ET tube marking is at the client's incisor -Disconnect the client from the ventilator and use the manual resuscitation bag -STAT page the respiratory therapist;Mechanical intubation complications (answer) Hypotension Fluid retention VAP High risk for stress ulcers Barotrauma Volutrauma Stress ulcers Nutrition problems Muscle deconditioning Ventilator dependence;Low pressure alarm (answer) Disconnection, cuff leak, displacement;High pressure alarm (answer) Indicate excess secretions, client biting the tubing, kinks in the tubing, client coughing, pulmonaryedema, bronchospasm, or pneumothorax;What to do in the case of a vent alarm going off (answer) -Always assess to see what is going on and why the alarm is going off -If you tried to troubleshoot and the patient is fine, disconnect the tubing and use the ambu bag, call the RT;VAP protocol (answer) -Keeping the head of the bed elevated at least 30 degrees -Performing oral care per agency policy (usually brushing teeth with a suction toothbrush at least every 12 hours and antimicrobial rinse) BEST IS EVERY 2 HOURS -Ulcer prophylaxis → PPI and H2 blockers -Preventing aspiration -Pulmonary hygiene, including chest physiotherapy, postural drainage, and turning and positioning;Shock physical assessment findings (answer) -Decreased bloodpressure with NARROWED pulse pressure -Decreased MAP;Shock initial stage (answer) -Decrease in the mean arterial pressure of 5-10 mmHg from baseline value -Increased sympathetic stimulation -Mild vasoconstriction -Increased heart rate;Shock compensatory mechanisms (answer) -Increased heart rate -Increased respiration rate -Decreased urine output -Stimulation of the thirst reflex -Pallor;Shock compensatory stage (answer) -Decrease in MAP of 10-15 mmHg from baseline value -Continued sympathetic stimulation -Moderate vasoconstriction -Increased heart rate -Increased respiration rate -Decreased urine output -Stimulation of the thirst reflex -Pallor -Mild acidosis -Mild hyperkalemia -Decreased pulse pressure;Shock progressive stage (answer) -Decrease in MAP of >20 mmHg from baseline value -Anoxia of non-vital organs -Overall metabolism is anaerobic -Moderate acidosis -Moderate hyperkalemia -Tissue ischemia;Shock refractory stage (answer) -Severe tissue hypoxia with ischemia and necrosis -Release of myocardial depressant factor from the pancreas -Buildup of toxic metabolites -MODS -Death;General shock labs (answer) ABGs -Decreased tissue oxygenation -Decreased pH -Decreased PaO2 -Increased PaCO2 Increased lactic acid -Normal range 0.5-1.0 mmol/L -Increased lactic acid causes metabolic acidosis Increased potassium -Normal range 3.5-5 mmol/L Increased blood glucose;Cardiogenic shock labs (answer) -Elevated cardiac enzymes -Elevated BNP;Hypovolemic shock labs (answer) -Decreased Hgb and Hct with hemorrhage -Increased Hgb and Hct with dehydration;Shock positioning (answer) -Extremities elevated 20 degrees -Knees straight -Head slightly elevated (modified Trendel);A client thought to be at risk for distributive shock is given a drug that constricts blood vessels. What effect does the nurse expect the drug to have on the client's mean arterial pressure (MAP)? (answer) Increased MAP without a change in vascular volume;Which new assessment finding in a client being treated for hypovolemic shock indicates to the nurse that interventions are currently effective? (answer) Serum lactate and serum potassium are declining;Ascites (answer) Abnormal accumulation of fluid in the abdomen; NUR2755 / NUR 2755 Multidimensional Care IV / MDC 4 Exam 3 Review (Latest 2022 / 2023) Rasmussen NUR2755 / NUR 2755 Multidimensional Care IV / MDC 4 Exam 3 Review (Latest 2022 / 2023) Rasmussen 1. muscle weakness increase uncordination confusion apathy incoherence decreased clotting Pneumothorax interventions MS physical assessment Frsotbite physical assessment Moderate hypothermia symptoms 2. worst headache ever subarachnoid hemorrhage symptom Spinal Cord Injury Intervention Right hemisphere stroke changes Guillian Barre Syndrome patho 3. infection vaccine autoimmune ARF ABG's 1 of 45 4/6/2021, 10:31 GBS causes ARDS Phases MG causes 4. comprehensive head to toe diagnostic labs insertion-GI tube, cath temporary dressing splints to fractures Secondary survey P.E. Intervention decoricate posture ARF oxygenation 5. nonpurposeful, stereotyped, and repetitive behaviors that commonly accompany focal impaired awareness seizures (in the semiologic classification, they define automotor seizures). The behavior is inappropriate for the situation. Patients are usually amnestic to their automatisms. complex/automatism seizure seizure phase Prodomal Seizure phase post ictal tonic-clonic seizure (grand mal) 6. stereotactic pallidotomy- destroy a portion of the globus pallidus, and thereby, decrease patients' muscle rigidity from Parkinson's disease DBS-uses electrical stimulation to modulate these control centers deep to the surface of the brain, improving communication between brain cells. This helps to reduce symptoms such as tremor, slowness, and stiffness. 2 of 45 4/6/2021, 10:31 Parkinson's surgical treatment Heat exhaustion interventions Parkinson's lab tests Parkinson's 4 cardinal symptoms 7. CSF mahave low dopamine MRI or SPECT to rule out other brain conditions Parkinson's drug treatment MG non-surgical interventions Parkinson's lab tests ARF interventions 8. lack of meds, give a med and see if it helps Myasthenic crisis Cushing triad Myasthenia Gravis patho Non urgent triage 9. complete- no function below injury incomplete-some function below injury Spinal cord injury complete vs incomplete Spinal Cord Injury Intervention 3 of 45 4/6/2021, 10:31 Triage rules HEat stroke prehospital interventions 10. Tonic-clonic tonic clonic myoclonic atonic Multiple sclerosis patho Generalized Seizures types Seizure Diagnostic testing Severe hypothermia symptoms 11. could wait several hours and survive ex. rash strains and sprains colds simple fractures Non urgent triage ARF interventions Myasthenic crisis Vent care 12. ABC's peripheral pulses and cap refill hemmorage check Glascow coma scale spinal shock- loss of motor, reflexes 4 of 45 4/6/2021, 10:31 assess mobility/function assess bowel activity Spinal cord injury physical assessment Stroke Risk factors non modifiable Causes fo seizures secondary Heat stroke hospital interventions 13. thyroid function SPEP AChR antibodies chest xray/ct RNS EMG Tensilon test MuSK antibodies parkland formula MG lab diagosis ARF oxygenation MG causes 14. sudden rise in BP with Bradycardia profuse sweating above injury flushing of skin blurred/spots in vision nasal congestion severe, throbbing headache Clonic seizures Shock drugs 5 of 45 4/6/2021, 10:31 autonomic dyreflexia Autonomic Dysreflexia causes 15. Rapid ID-hemmy or ischy CT scan Glucose stick Give ateplase if ischy ICU frequent vitals Hemmy-prep for surgery Stroke Initial assessment Severe hypothermia symptoms Stroke emerency interventions Heat exhaustion interventions 16. dyspnea low O2 irritable confused tachycardia decreased loc headache drowsy GBS physcial assessment ARDS physical assessment Glascow coma scale scores Mass causualty triage tags 6 of 45 4/6/2021, 10:31 17. ulcers-PPI-dine H2 blocker prazole enteral feeding electrolyte replace Heat exhaustion interventions Frsotbite physical assessment Mass causualty triage tags Vent complications and prevention 18. sudden dyspnea sharp stabbing chest pain anxiety cough tychypnea crackles pleural friction rub s3 or s4 sounds diaphoresis fever decreased SaO2 Pneumothorax interventions Plasmaphersis watch out for ARDS Physcial Assessment P.E. physical assessment 19. prevent heat loss warm up no booze blankets supine space out meds withhold IV meds until core temp 86 or higher monitor for vfib 7 of 45 4/6/2021, 10:31 rewarm trunk P.E. Intervention Severe hypothermia symptoms autonomic dyreflexia Hypothermia interventions 20. abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight Increased ICP symproms MS Lab diagnostics decoricate posture ARDS Interventions 21. Preventative: Avonex Betaseron Copaxon Acute-steroids and baclofen Shock drugs MS Drugs Cushing triad ARF ABG's 22. distorted acetylcholine receptors 8 of 45 4/6/2021, 10:31 hyperplasia of thymus gland ARDS Phases GBS causes MG causes P.E. Surgery 23. tumor or trauma metabolic disroders acute alchohol withdrawl electrolyte imbalance fever stroke TBI substances heart disease Causes fo seizures secondary Stroke emerency interventions Severe hypothermia symptoms Causes of seizures Primary 24. idiopathic genetic factors Generalized Seizures types Causes of seizures Primary partial seizure types Causes fo seizures secondary 25. thymectomy Anaphylaxis bee treatment MG non-surgical interventions P.E. physical assessment MG surgical intervention 26. tremor muscle rigidity bradykinesia or askinesia (slow or no movement) postural instability Parkinson's surgical treatment Parkinson's Physcial assessment Parkinson's 4 cardinal symptoms Parkinson's drug treatment 27. vagal nerve stimulation-prevents seizures by sending regular, mild pulses of electrical energy to the brain via the vagus nerve. It is sometimes referred to as a "pacemaker for the brain." A stimulator device is implanted under the skin in the chest. A wire from the devic