NUR 413 Complex Care Final Exam
Abdominal Injuries Correct Answer Liver
Spleen
Gastric and small bowel injuries
Kidney
Pelvic structure disruption
Abnormal respiratory patterns Correct Answer
Abnormalities related to Antidiuretic hormone (ADH) Correct
Answer AntiDIURETIC hormone --> think of anti diuresis -->
anti-urination --> less urination (ADH --> WATER IN THE
BODY!)
Produced in the hypothalamus, stored in posterior pituitary
Acts on distal renal tubule --> reabsorption of water
Acts on smooth muscles of arterioles --> vasoconstriction (@
high doses)
Regulates
WATER balance
Serum osmoloality
* More "stuff" and less fluid in the blood= higher osmolality
* Less "stuff" and more fluid= lower osmolality
Acute Care Phase Correct Answer Begins 48 to 72 hours after
injury
,Continue with assessments performed during resuscitative phase
Focus of interventions are to:
* Promote wound healing
* Prevent complications
* Improve function of body systems (systemic response to burn
injury)
Blood and electrolytes:
* Fluid shifts
* Electrolyte imbalances
Acute Kidney Injury Correct Answer Sudden decline in
kidney function causing a disturbance in fluid, electrolyte, and
acid/base balance
Advantages of PD Correct Answer Machine free
Done while you go about normal activities
Drain later
Can do it yourself
All tubing must be changed within how many hours of the
initiation of the transfusion? Correct Answer 24 hours
Asymptomatic Anemia Correct Answer Preoperative
hemoglobin less than 8 AND
Anticipated surgical blood loss greater than 500 mL
,Autoregulation Correct Answer The process where brain
maintains its perfusion pressure over a wide range of systemic
pressures
Highly dependent upon MAP
Babinski reflex Correct Answer Normal finding in children up
to the age of 2 years due to underdeveloped nervous system;
however, it is abnormal in clients older than 2 years
If positive in someone older than 2 years, it is considered
"pathologic" in nature; its presence can be a temporary or
permanent assessment finding, which simply means damage to
the nerve paths connecting the spinal cord to the brain
Basilar skull fracture Correct Answer Raccoon eyes
Periorbital edema ecchymosis
Rhinorrhea
Postauricular ecchymosis
Blood
Otorrhea
Yellow - CSF
Red - Blood
Bispectral index monitoring Correct Answer GOAL is BIS <
60 in critically ill requiring sedation
BIS values range from 0-100
BIS > 90 fully conscious/awake
BIS > 60 patient aware/recollection
BIS 40-60 deep sedation
, Blast Trauma Correct Answer Form of blunt and penetrating
trauma
Primary: Shock waves change air pressure and tissue damage
results when the pressure waves pass through the body
Secondary: Debris impales body from negative pressure
Tertiary: Body thrown by force of explosion causing blunt
injury (usually closed head)
Quaternary: Chemical, thermal, or biological exposure
Blood products must be started within how many minutes of
receipt from blood bank? Correct Answer 20 minutes...after
20 minutes, unit not returnable to blood bank
Blood tubing should be changes after every...? Correct Answer
4 units; IV pump blood tubing may be used for 5-10 units
Blunt Trauma Correct Answer Most common mechanism of
injury
MVA, assaults with blunt objects, falls, sports-related injuries,
and pedestrians hit by motor vehicle
Occurs with rapid deceleration
Movement ceases and contents of body continue to travel within
an enclosed space
Abdominal Injuries Correct Answer Liver
Spleen
Gastric and small bowel injuries
Kidney
Pelvic structure disruption
Abnormal respiratory patterns Correct Answer
Abnormalities related to Antidiuretic hormone (ADH) Correct
Answer AntiDIURETIC hormone --> think of anti diuresis -->
anti-urination --> less urination (ADH --> WATER IN THE
BODY!)
Produced in the hypothalamus, stored in posterior pituitary
Acts on distal renal tubule --> reabsorption of water
Acts on smooth muscles of arterioles --> vasoconstriction (@
high doses)
Regulates
WATER balance
Serum osmoloality
* More "stuff" and less fluid in the blood= higher osmolality
* Less "stuff" and more fluid= lower osmolality
Acute Care Phase Correct Answer Begins 48 to 72 hours after
injury
,Continue with assessments performed during resuscitative phase
Focus of interventions are to:
* Promote wound healing
* Prevent complications
* Improve function of body systems (systemic response to burn
injury)
Blood and electrolytes:
* Fluid shifts
* Electrolyte imbalances
Acute Kidney Injury Correct Answer Sudden decline in
kidney function causing a disturbance in fluid, electrolyte, and
acid/base balance
Advantages of PD Correct Answer Machine free
Done while you go about normal activities
Drain later
Can do it yourself
All tubing must be changed within how many hours of the
initiation of the transfusion? Correct Answer 24 hours
Asymptomatic Anemia Correct Answer Preoperative
hemoglobin less than 8 AND
Anticipated surgical blood loss greater than 500 mL
,Autoregulation Correct Answer The process where brain
maintains its perfusion pressure over a wide range of systemic
pressures
Highly dependent upon MAP
Babinski reflex Correct Answer Normal finding in children up
to the age of 2 years due to underdeveloped nervous system;
however, it is abnormal in clients older than 2 years
If positive in someone older than 2 years, it is considered
"pathologic" in nature; its presence can be a temporary or
permanent assessment finding, which simply means damage to
the nerve paths connecting the spinal cord to the brain
Basilar skull fracture Correct Answer Raccoon eyes
Periorbital edema ecchymosis
Rhinorrhea
Postauricular ecchymosis
Blood
Otorrhea
Yellow - CSF
Red - Blood
Bispectral index monitoring Correct Answer GOAL is BIS <
60 in critically ill requiring sedation
BIS values range from 0-100
BIS > 90 fully conscious/awake
BIS > 60 patient aware/recollection
BIS 40-60 deep sedation
, Blast Trauma Correct Answer Form of blunt and penetrating
trauma
Primary: Shock waves change air pressure and tissue damage
results when the pressure waves pass through the body
Secondary: Debris impales body from negative pressure
Tertiary: Body thrown by force of explosion causing blunt
injury (usually closed head)
Quaternary: Chemical, thermal, or biological exposure
Blood products must be started within how many minutes of
receipt from blood bank? Correct Answer 20 minutes...after
20 minutes, unit not returnable to blood bank
Blood tubing should be changes after every...? Correct Answer
4 units; IV pump blood tubing may be used for 5-10 units
Blunt Trauma Correct Answer Most common mechanism of
injury
MVA, assaults with blunt objects, falls, sports-related injuries,
and pedestrians hit by motor vehicle
Occurs with rapid deceleration
Movement ceases and contents of body continue to travel within
an enclosed space
