MDC4 Final Exam - Questions with Complete Solutions, Exams of Nursing

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MDC4 Final Exam -QUESTIONS WITH COMPLETE SOLUTIONS.LATEST UPDATE 2023 / 2024.Top Ranked What does triaging do? - ✔✔️*️acts as gatekeeper* helps prioritize patient care based on illness and severity level According to triage, what patients would be seen firtst - ✔✔️h️ighest acuity patients will receive quickest intervention (Most ill/severe will get seen first) What is a good model for triaging patients? - ✔✔️A️BCs Is hospital triaging the same as mass casualty triaging? - ✔✔️N️O Which triage situation uses tags? - ✔✔️m️ass casualties what are the categories of triage? - ✔✔️-️ emergent - urgent - nonurgent - primary survey what classifies a patient as emergent according to triage - ✔✔️-️ life threatening injuries - needs immediate treatment what patient conditions warrant an emergent status of triage - ✔✔️-️ respiratory distress - chest pain with diaphoresis - stroke - active hemorrhage - unstable vitals what classifies a patient as urgent according to triage - ✔✔️p️atient should be treated quickly but there is not and immediate threat to life what patient conditions warrant an urgent status for triage - ✔✔️-️ severe abdominal pain - renal colic - displaced multiple fractures - new onset of respiratory infection (pneumonia) what classifies a patient as nonurgent according to triage - ✔✔️p️atient can wait several hours without a risk to life what patient conditions warrant a nonurgent status for triage - ✔✔️-️ skin rash - strains/sprains - colds - simple fracture what is a primary survey that should be performed while triaging? - ✔✔️A️BCDE if heat exhaustion goes untreated, what can it cause? - ✔✔️h️eat stroke what are the s/s of heat exhaustion - ✔✔️-️dehydration -decrease in blood volume -decrease in BP -tachycardia what is the first intervention for a person expected to have heat exhaustion? - ✔✔️s️top their physical activity and transfer to a cool place what is the quickest way to reduce someone's temperature? - ✔✔️-️ remove clothing - remove bed linen what interventions are there for cooling patients down? - ✔✔️-️ cold pack on the neck, chest, abdomen, and groin - soak in cool water when rehydrating someone with heat exhaustion, should you use water or a sports drink/oral reydration solution? - ✔✔️S️ports drink/oral hydration solution why is a sports drink better at rehydrating patients with heat exhaustion? - ✔✔️p️lain water can worsen sodium deficits nursing care for patients hospitalized with heat exhaustion - ✔✔️-️ monitor vitals - administer .9% NS in N/V is present - draw labs to check electrolytes how is heat stroke defined? - ✔✔️b️ody temperature greater than 104F T/F: heat stroke is a medical emergency - ✔✔️T️RUE T/F: if heat stroke is left untreated it becomes fatal - ✔✔️T️RUE s/s of heat stroke - ✔✔️-️ tachycardia - hallucinations - irregular pulse - decreased urin output - hot and dry skin nursing care for heat stroke - ✔✔️-️ 02 and .9% NS via IV - continuous cooling, IVF, and cooling blankets. when should continuous cooling, IVF, and cooling blankets be stopped? - ✔✔️w️hen core temperature reaches 102F what should you do if your patient is shivering while being cooled from heat stroke? - ✔✔️a️dminister benzos because they provide sedation, control convulsions, and control shivering what should you NOT administer for a person with a high body temperature - ✔✔️-️ aspirin - antipyretics at what temperature does hypothermia occur? - ✔✔️l️ess than 95F nursing care for hypothermia - ✔✔️-️ find shelter away from cold - remove wet clothing - monitor for cardio issues, ARDS, pneumonia - focus on rewarming slowly in hypothermia, why should cardo issues be monitored? - ✔✔️d️ysrhythmias could result from lactic acid build up what is frostbite - ✔✔️f️reezing of body tissue how many degrees of frostbite are there? - ✔✔️4️ what happens with 1st degree frostbite? - ✔✔️h️yperemia and edema (hyperemia: increased blood flow) what happens with 2nd degree frostbite? - ✔✔️-️ red area - blisters with clear/milky fluid - partial thickness necrosis what happens with 3rd degree frostbite - ✔✔️-️ small blisters with dark fluid - next of kin what is the color system for triage tagging - ✔✔️-️ green - yellow - red - black what does the color green mean in triage? - ✔✔️n️on-urgent/walking, talking what does yellow mean in triage - ✔✔️u️rgent but not life threatening what does the red tag mean in triage - ✔✔️e️mergent could die if not treatment but have better odds what does black mean in triage - ✔✔️d️o not attempt to treat them because their injuries are too extensive and will die regardless interventions to manage stress - ✔✔️-️ develop a buddy system w/ coworker - have well balanced meals - drink alot of water - take breaks - do not exceed more than 12hrs/day - stay in touch with friends/family - crisis debriefing - take a few minutes each shift to decompress MRC - ✔✔️M️edical Reserve Corps why is MRC a thing? - ✔✔️C️reated for volunteers in the community who want to donate their time ad expertise to prepare for and respond to emergencies on a local scale DMAT - ✔✔️D️isaster Medical Assistance Team what does DMAT do - ✔✔️t️hey are federal employees who make up a medical relief team made up of civilians who's license is valid in all states when working how can a person be prepared for disasters - ✔✔️h️ave a go bag with personal readiness supplies **should be enough for three days at least what is an internal disaster - ✔✔️a️nything impacting inside the hospital examples of an internal disaster - ✔✔️-️ fire - water pipe burst - power outage - shooting at Seattle Grace what is an external disaster - ✔✔️A️ disaster that occurs in the community and may be natural, manmade, or terror-induced examples of external disasters - ✔✔️-️ earthquake - flood - car pile up - ferry boat crash What is the most common type of dementia? - ✔✔️A️lzheimer's disease Is Alzheimer's reversible? - ✔✔️N️o What is the etiology of Alzheimer's? - ✔✔️U️nknown Alzheimer's is the result of? - ✔✔️c️hanges in personality, memory, and/or judgement What are risk factors for Alzheimer's? - ✔✔️*️ 65+ years * female * head injury * APOE gene what is the patho of Alzheimer's - ✔✔️p️laques, tangles, degeneration of neurons How is Alzheimer's diagnosed? - ✔✔️b️iopsy at autopsy is the only definitive way but dementia can be ruled out with CT, labs, UA, and MRI - Levodopa (increases dopamine levels in CNS) and Carbidopa (prevents levodpa breakdown) - take at same time every day - know that increased protein can alter effectiveness - Benztropine - decreases Ach levels What are headaches? - ✔✔️v️asodilation of blood vessels in the brain What causes headaches - ✔✔️g️enetics, stress, hormones What can trigger a headache? - ✔✔️c️offee, yogurt, alcohol, MSG, marinated foods s/s of headache - ✔✔️h️ead pain for 4-72 hours, N/V, unilateral pain, may come with aura what are cluster headaches? - ✔✔️h️appen at night, stuffy nose treatment of headache - ✔✔️P️rophylactic = propranolol Mild = NSAID Severe = sumatriptan - ergotamine tartrate - 6 tabs in 1 day - take as soon as pain starts - MOA = constricts cerebral blood vessels What is increased ICP made of? - ✔✔️C️SF, blood, brain what causes increased ICP - ✔✔️i️nfection, trauma, increased CSF, hemorrhage, tumors s/s of increased ICP - ✔✔️M️IND CRUSH M: mental status change (early sign) = decreased LOC, irritable, confusion I: irregular breathing (late sighn) = Cheyene Stokes N: nerve damage to eye = pupil changes D: decerebrate (limbs out) and decorticate (limbs to core) posturing C: cushing's triad (late) = HTN + brady + wide pule pressure R: reflux - N/V U: unconscious S: seizures H: headaches Nursing care for Increased ICP - ✔✔️P️RESS P: position HOB @ 30 degrees and make sure body's midline (no flexion of neck or hips) R: respiratory we want to prevent hypercapnia by hyperventilating (limit suctioning) E: elevated temp - prevent it! S: system checks = neuro checks S: straining things - avoid it (no lifting, blowing nose, cough/sneeze) Additional Nursing care measures for ICP - ✔✔️-️ turn down the lights - no TV or noise - put sign on door telling visitors to see nurse first What do you NOT do when someone has increased ICP? - ✔✔️L️umbar Puncture What is the Glasgow Coma Scale? - ✔✔️-️A brain injury severity scale that assesses depth and duration of impaired consciousness and coma. what 3 areas make up the Glasgow coma scale? - ✔✔️-️ eyes score 1-4 - verbal score 1-5 - motor score 1-6 Total score 3-15 **lower the score = more severe injury/status Eyes for Glasgow Coma Scale - ✔✔️E️SPN E - eyes open spontaneously (4) S - sound (3) P - pain (2) N - not open (1) nursing care during siezure - ✔✔️-️ turn patient on left side (#1) - loosen restrictive clothing - note onset and duration - do NOT insert anything by mouth Nursing care after seizure - ✔✔️-️ take vitals - perform neuro checks - determine what trigger was - maintain left lying position Treatment of seizures - ✔✔️P️henytoin - narrow range (10-20), s/s= gingival hyperplasia Valproic acid - s/s = hepatotoxic Carbamazepine - can cause a rash (Steven Johnson syndrome) Education for Seizures and Seizure treatment - ✔✔️-️ medication compliance (abrupt withdrawal = rebound seizures) - do not drive - wear medical alert bracelet surgical treatment of seizure - ✔✔️-️ vagal nerve stimulator - craniotomy What is encephalitis? - ✔✔️i️nfection & inflammation of the brain tissue ***life threatening How is encephalitis diagnosed? - ✔✔️C️SF analysis or EEG What are the s/s of encephalitis? - ✔✔️s️tiff neck, n/v, fever What can encephalitis increase risk of? - ✔✔️i️ncreased ICP Nursing care for encephalitis - ✔✔️-️ turn down lights and noise - keep midline and HOB @ 30 degrees - avoid straining activities What is meningitis - ✔✔️i️nflammation of meninges (around brain and spinal cord) what are the two main types of meningitis - ✔✔️1️. viral - more common 2. bacterial - cause is step Prevention of meningitis - ✔✔️v️accination - Hib for baby - MCV4 for teens Diagnosis of meningitis - ✔✔️C️SF analysis What does CSF analysis look like for viral meningitis? - ✔✔️c️lear, increased wbc and protein what does CSF analysis look like for bacterial meningitis - ✔✔️c️loudy, decreased glucose, increased wbc, and protein s/s of meningitis - ✔✔️n️uchal rigidity, n/v, photophobia, Brudzinski's sign, Kernig's sign What is Brudzinski's sign? - ✔✔️A️fter forced flexion of the neck there is a reflex flexion of the hip and knee and abduction of the leg. What is Kernig's sign? - ✔✔️A️fter flexing the hip and knee at 90 degree angles, pain and resistance are noted. Nursing care for Meningitis - ✔✔️-️ bacterial = antibiotics - viral = acyclovir - steroids (decrease inflammation, increased infection) - prophylaxis treatment for anyone in contact/exposed - implement droplet precautions for first 24 hours of treatment Action: elevate HOB, Remove restrictive clothing, schedule bowel and bladder maintenance What is true for spinal cord injury - ✔✔️t️he higher the injury, the more system affected and shorter the lifespan diagnosis of spinal cord injury - ✔✔️X️-ray, CT scan, MRI prevention of spinal cord injury - ✔✔️s️top drugs and alcohol causes of spinal cord injury - ✔✔️t️raumatic: falls, MVA, violence Non-traumatic: tumors, RA Direct: fracture, hyperflexion (diving), hyperextension, penetration (GSW), axial load types of spinal cord injuries - ✔✔️C️omplete: complete severed spinal cord, complete loss of function below injury Incomplete: spinal cord is partially severed, partial loss of function Quadriplegia - at C6 - Unable to move all 4 extremeties - MVA, fall Paraplegia - below T1, paralysis of lower extremities, can be result of GSW what is the main cause of death for people with spinal cord injuries - ✔✔️s️epsis, pneumonia, PE Acute management of spinal cord injury - ✔✔️-️ airway and breathing - immobilize head and neck (c-collar) - determine LOC by using GCS Medications for spinal cord injuries - ✔✔️-️ corticosteroid = methylprednisolone - first given as IV bolus - then IV continuous drip for 24 hours - needs to be given w/in 8 hrs of injury -s/s hyperglycemia, poor wound healing, infection - education: increae Ca intake, ROM, deep breathing what is the number 1 thing to keep in mind with a spinal cord injury? - ✔✔️A️IRWAY and BREATHING Complications of Spinal cord injury - ✔✔️-️ autonomic dysreflexia - neurogenic shock (hypo, bready, edema, temp) what is a stroke? - ✔✔️a️lteration in blood flow to the brain TIA - ✔✔️t️ransient ischemic attack = mini stroke, warning sign diagnosis of stroke - ✔✔️C️T without contrast Etiology of stroke - ✔✔️-️ nonmodifiable = age, sex, history - modifiable = HTN, BC user, high cholesterol, smoker s/s of stroke - ✔✔️F️AST facial droop, arm drift, speech is slurred, time how much as passed General Left vs Right side stroke - ✔✔️L️eft = language Right = impulse & judgement Left-sided stroke s/s - ✔✔️-️ receptive aphasia (unable to verbally communicate back) - right sided hemiparesis (weakness) - agraphia (unable to right) - Aware of their deficits - anxiety and depression Right-sided stroke s/s - ✔✔️-️ poor impulse control and judgement - 1 sided neglect syndrome (unaware of deficits on left side of body, big safety concern) - short attention span - proprioception (depth) issues - blowing/inserting = NO - prevent increased ICP Complications of ICP - ✔✔️h️ydrocephalus, infection, stroke, increased ICP meds for icp - ✔✔️a️ntiseizure, mannitol, corticosteroids what are the assessment findings in pneumothorax? - ✔✔️●️ Sudden dyspnea ● Chest pain ● Feeling of doom/anxiety ● JVD ● Tachy ● Chest petechiae ● ECG changes ● Abnormal heart sounds what are the s/s of flail chest - ✔✔️-️ paradoxical chest movement - dyspnea - cyanosis - tachycardia - hypotension how does the patient usually present with flail chest - ✔✔️-️ anxious - short of breath - in pain what are interventions for flail chest - ✔✔️-️ humidified oxygen - pain management - promotion of lung expansion through deep breathing and positioning - secretion clearance by coughing and tracheal suction can a person with flail chest recover - ✔✔️m️anagable with vigilant respiratory care when is mechanical ventilation needed for a patient with flail chest - ✔✔️-️ respiratory failure - shock - severe hypoxemia and hypercarbia nursing care for flail chest - ✔✔️-️ monitor ABGs - monitor vitals with flail chest, what causes increase the risk of respiratory failure - ✔✔️-️ lung contusion - underlying pulmonary disease how is flail chest usually stabilized - ✔✔️p️ositive pressure ventilation what interventions are needed for low BP - ✔✔️-️ fluid replacement - Trendelenburg - compression stockings - medication what causes a high pressure vent alarm - ✔✔️-️ thick mucus/secretions blocking the airway - coughing - biting on tube - fighting vent - wheezing - bronchospasms - pneumothorax - displaced tube - obstruction - water in vent circuit what causes a low pressure vent alarm - ✔✔️-️ leak in circuit - cuff leak - patient disconnected *apnea alarm* possible interventions for high pressure vent alarm - ✔✔️-️ check patient first! - check all tubing is connected and not kinked - suction patient - medication for pain, anxiety, sedation - change vent settings - ulcer prophylaxis (famotidine/Pepcid) what does ARDS stand for - ✔✔️a️cute respiratory distress syndrome what intervention is done for a healthy person who sustains an acute lung injury - ✔✔️m️echanical ventilation pathophysiology of ARDS - ✔✔️i️ncreased alveolar permeability + leaking of fluid = alveolar collapse what causes ARDS - ✔✔️-️ sepsis - burns - pancreatitis - transfusion - trauma - diffuse pulmonary infection - gastric aspiration - O2 toxicity - lung contusion s/s of ARDS - ✔✔️-️ persistent hypoxia (even with O2 therapy) - dyspnea - decreased pulmonary compliance - non cardiac pulmonary edema how to diagnose ARDS - ✔✔️-️ refractory hypoxia - chest x ray shows glossy + white out (diffuse patchy infiltrates) - normal wedge pressure - pO2/FIO2 < 200 phases of ARDS - ✔✔️-️injury (exudative) phase - alveolar collapse - refractory hypoxemia -reparative (proliferative) phase - decreased lung compliance -fibrotic phase - surfactant cells are damaged assessment of patient on vent - ✔✔️-️ vitals - O2 saturation - auscultate breath sounds - pain/anxiety - tube placement - vent settings nursing care for ARDS - ✔✔️-️ ET + Mechanical vent w/ PEEP or CPAP - light IV fluids, diuretics, antibiotics - start nutrition (TPN or tube feeds) risk factors for pulmonary embolism (PE) - ✔✔️-️ immobile, obese, advanced age, surgery - central venous catheter, embolic event history - pregnancy, oral contraceptives, estrogen therapy - heart failure, trauma, smoker assessment findings for PE - ✔✔️-️ sudden dyspnea - chest pain - feeling of impending doom - JVD - tachy - chest petechiae - ECG changes - abnormal heart sounds normal INR range - ✔✔️0️.8-1.2 normal INR range while on Warfarin (Coumadin) for PE - ✔✔️2️-3 normal PT range - ✔✔️1️1-12.5 seconds normal PT range while on Warfarin for PE - ✔✔️1️.5-2 times base, so 22-25 normal range for aPTT - ✔✔️2️0-30 seconds - hypothermia neurogenic shock treatment - ✔✔️-️ establish circulatory blood volume - administer atropine for low heart rate - keep patient warm - prep to intubate what is DIC - ✔✔️d️isseminated intravascular coagulation what does DIC cause - ✔✔️a️bnormal coagulation involving fibrinogen - excessive clotting along with hemorrhage at the same time treatment of DIC - ✔✔️-️ blood transfusion - FFP (fresh frozen plasma) - fluid replacement lab values for lactate during hypovolemic shock - ✔✔️>️2 indicates shock medication for hypovolemic shock - ✔✔️v️asopressors what do vasopressors do - ✔✔️i️ncrease the workload of the heart what does vasopressin do - ✔✔️-️ causes vasoconstriction (increase BP) - reabsorption of water in the renal tube - increases blood flow to the heart and brain interventions for burns - ✔✔️-️ secure airway - support circulation (fluid replacement) - prevent infection - maintain body temperature - provide emotional support what causes dry heat burns - ✔✔️o️pen flames what causes moist heat burns - ✔✔️h️ot liquids what causes contact burns - ✔✔️h️ot metal, tar, or grease what causes chemical burns - ✔✔️a️lkali, acids, organic compounds *alkali burns are worse than acid burns* what causes electrical burns - ✔✔️e️lectrical current enters the body what causes radiation burns - ✔✔️s️unburns or radiation treatment for cancer Rule of 9's for burns - ✔✔️H️ead = 9% Arms = 18% (9% each) Back = 18%, Front/chest 18% Legs 36% (18% each) Genitalia = 1 what is an escharotomy - ✔✔️i️ncision through eschar relieves pressure from constricting force of fluid buildup under circumferential burns on the extremity or chest and improves circulation inhalation injury assessment - ✔✔️-️ face or neck burns - singed nasal hairs - soot in upper airway - assess sputum with a superficial (1st degree) burn, what layer of skin is affected - ✔✔️e️pidermis with a partial thickness (2nd degree) burn, what layer of skin is affected - ✔✔️-️ epidermis - partial dermis - hair follicles intact with a full thickness (3rd degree) burn, what layer of skin is affected - ✔✔️-️ epidermis - dermis - SQ - possible muscle and bone what is the healing time for a partial thickness (2nd degree) burn - ✔✔️s️uperficial: 5-21 days deep: 22-35 days what is the healing time for a full thickness (3rd degree) burn - ✔✔️n️o healing potential what are treatment interventions for a superficial (1st degree) burn - ✔✔️-️ mild analgesia what are treatment interventions for a partial thickness (2nd degree) burn - ✔✔️d️eep burns may require grafting what are treatment interventions for a full thickness (3rd degree) burn - ✔✔️-️ excision and grafting - amputation parkland formula for burns - ✔✔️4️ ml x Kg x % burn surface area give 1/2 fluids in first 8 hours. remaining 1/2 in last 16 hours. what fluid is given for burns - ✔✔️L️R or NS how to calculate MAP - ✔✔️(️SBP + 2DBP)/3 what labs are used to measure nutrition after burns - ✔✔️-️ albumin - prealbumin - total protein What are the different types of shock - ✔✔️-️ cardiogenic shock - hypovolemic shock - anaphylactic shock - septic shock - neurogenic shock what is cardiogenic shock due to - ✔✔️h️eart problems what is hypovolemic shock cause by - ✔✔️t️oo little blood volume what is anaphylactic shock caused by - ✔✔️a️llergic reaction what is septic shock due to - ✔✔️i️nfection what is neurogenic shock caused by - ✔✔️d️amage to the nervous system When do we consider a patient a candidate for trach placement after ET intubation? - ✔✔️p️atients with respiratory failure who cannot be weaned within 7-10 days are candidates for tracheostomy. Most severely injured trauma patients requiring intubation longer than 5 days will require airway support and will benefit from early tracheostomy