NUR 265 TEST 3 Study Guide Questions
and Answers with Complete Solutions
Galen College of Nursing
What causes Autonomic Dysreflexia - ANSWERS Stimulation at level of T6 or
above
What are some examples of triggers of autonomic dysreflexia - ANSWERS
restrictive clothing; full bladder/neurogenic bladder; fecal impaction; directive
pressure s/a sitting in the wheel chair
signs and systems of Autonomic Dysreflexia - ANSWERS 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 - ANSWERS
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 - ANSWERS
Lactated ringers
Chemical burns should be irrigated until - ANSWERS 20 minutes or the burn
sensation continues after the 20 minute marker
,what would you use to remove hot tar or asphalt - ANSWERS 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 - ANSWERS cortical and premotor cortex damage
what kind of brain injury would you expect if an adult client is positive for plantar
infant reflexes - ANSWERS upper motor neuron lesion
what kind of brain injury would you expect if an adult client is positive for rooting
infant reflex - ANSWERS frontal lobe damage
what kind of brain injury would you expect if an adult client is positive for sucking
infant reflex - ANSWERS 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 - ANSWERS diffuse cortical dysfunction
What is the consensus formula for burns - ANSWERS 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 - ANSWERS Restlessness, anxiety, Hypothermia
,how much fluid replacement are you going to give the first 8 hours - ANSWERS
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 - ANSWERS Urine output
Besides a hyperbaric chamber how would you admin o2 to a client with CO
poisoning - ANSWERS 100% O2 with a non-rebreather
How would you treat a circumferential trunk burn that is swelling and why? -
ANSWERS Eschartomies R/T constriction of the chest wall expansion
what are the classification of shock - ANSWERS Cardiogenic; hypovolemic,
neurogenic, and Disruptive
All shock is caused by - ANSWERS inadequate tissue perfusion
Patho of hypovolemic shock - ANSWERS Inadequate circulating blood volume
S/A burns, hemorrhage, dehydration
Patho for cardiogenic shock - ANSWERS Inadequate pumping action of the
heart S/A MI, CHF, PE
What are the 3 subclasses of Distributive shock - ANSWERS Anaphylactic;
Septic; Neurogenic
, Patho for neurogenic shock - ANSWERS interference of the nervous system
that controls the blood vessels
Patho for septic shock - ANSWERS 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 - ANSWERS 15-25%, or 1/3 of the body blood, or 5L
clients who experience slow blood loss can - ANSWERS Tolerate the blood loss
better then a client with rapid blood loss
Signs and symptoms of compensatory shock - ANSWERS hypotension,
tachycardia, tachypnea, hypothermia, decrease pulse pressure
During compensatory stage of shock, why would you hear hypoactive bowl sounds
and cool and clammy skin - ANSWERS Body shunting blood from skin, kidneys
and GI to provide adequate blood volume to the brain and heart
Why would urine output decrease during compensatory stage of shock -
ANSWERS High production of aldosterone
why do RR increase in compensatory stage of shock - ANSWERS The body is
going into acidotic state trying to blow it off Kussmals
What is the byproduct of anaerobic metabolism that is developing in what stage
of shock - ANSWERS Lactic acid, Compensatory
and Answers with Complete Solutions
Galen College of Nursing
What causes Autonomic Dysreflexia - ANSWERS Stimulation at level of T6 or
above
What are some examples of triggers of autonomic dysreflexia - ANSWERS
restrictive clothing; full bladder/neurogenic bladder; fecal impaction; directive
pressure s/a sitting in the wheel chair
signs and systems of Autonomic Dysreflexia - ANSWERS 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 - ANSWERS
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 - ANSWERS
Lactated ringers
Chemical burns should be irrigated until - ANSWERS 20 minutes or the burn
sensation continues after the 20 minute marker
,what would you use to remove hot tar or asphalt - ANSWERS 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 - ANSWERS cortical and premotor cortex damage
what kind of brain injury would you expect if an adult client is positive for plantar
infant reflexes - ANSWERS upper motor neuron lesion
what kind of brain injury would you expect if an adult client is positive for rooting
infant reflex - ANSWERS frontal lobe damage
what kind of brain injury would you expect if an adult client is positive for sucking
infant reflex - ANSWERS 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 - ANSWERS diffuse cortical dysfunction
What is the consensus formula for burns - ANSWERS 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 - ANSWERS Restlessness, anxiety, Hypothermia
,how much fluid replacement are you going to give the first 8 hours - ANSWERS
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 - ANSWERS Urine output
Besides a hyperbaric chamber how would you admin o2 to a client with CO
poisoning - ANSWERS 100% O2 with a non-rebreather
How would you treat a circumferential trunk burn that is swelling and why? -
ANSWERS Eschartomies R/T constriction of the chest wall expansion
what are the classification of shock - ANSWERS Cardiogenic; hypovolemic,
neurogenic, and Disruptive
All shock is caused by - ANSWERS inadequate tissue perfusion
Patho of hypovolemic shock - ANSWERS Inadequate circulating blood volume
S/A burns, hemorrhage, dehydration
Patho for cardiogenic shock - ANSWERS Inadequate pumping action of the
heart S/A MI, CHF, PE
What are the 3 subclasses of Distributive shock - ANSWERS Anaphylactic;
Septic; Neurogenic
, Patho for neurogenic shock - ANSWERS interference of the nervous system
that controls the blood vessels
Patho for septic shock - ANSWERS 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 - ANSWERS 15-25%, or 1/3 of the body blood, or 5L
clients who experience slow blood loss can - ANSWERS Tolerate the blood loss
better then a client with rapid blood loss
Signs and symptoms of compensatory shock - ANSWERS hypotension,
tachycardia, tachypnea, hypothermia, decrease pulse pressure
During compensatory stage of shock, why would you hear hypoactive bowl sounds
and cool and clammy skin - ANSWERS Body shunting blood from skin, kidneys
and GI to provide adequate blood volume to the brain and heart
Why would urine output decrease during compensatory stage of shock -
ANSWERS High production of aldosterone
why do RR increase in compensatory stage of shock - ANSWERS The body is
going into acidotic state trying to blow it off Kussmals
What is the byproduct of anaerobic metabolism that is developing in what stage
of shock - ANSWERS Lactic acid, Compensatory
