NUR 213 Exam 3

An olympic diver suffered a SCI and prior to having spinal shock 4 years ago. The patient is now in the ED. The patient is dehydrated but unable to drink water. Her most recent vitals are HR 48 SpO2 95 BP 150/92 RR 14. What med will the nurse administer? A. Methylprednisolone B. Nifedipine C. Hydralazine D. Levophed

C. Hydralazine

Which of the following patients would the emergency department nurse prioritize? A. The pt. who was in a MVC needing sutures for a gash on the right forearm B. The pt. who broke their R toe walking into a wall C. The pt. who has a GSW to the L hand D. The pt. who came in with alcohol poisoning and received gastric lavage

C. The pt. who has a GSW to the L hand Urgent

A nurse is assessing a client who is experiencing post-traumatic stress following a traumatic event. Which of the following medications should the nurse expect the provider? A. Bupropion B. Phenelzine C. Mirtazapine D. Paroxetine

D. Paroxetine AKA Paxil

A nurse is caring for a patient who is experiencing autonomic dysreflexia d/t a C5 spinal cord injury. After checking the patient's vital signs, which of of the following actions should the nurse perform next? a. Administer nifedipine b. Place the client in a high-Fowler's position c. Check for urinary retention d. Check for a fecal impaction

b. Place the client in a high-Fowler's position Rationale: ATI said so

Spinal shock clinical manifestation: a. Sudden depression of reflex activity above the level of spinal injury b. Hypotension, bradycardia, and decreased CO c. Loss of function of the autonomic nervous system d. Absent reflexes and a lack of sensation

d. Absent reflexes and a lack of sensation There is sudden depression of reflex activity BELOW the level of spinal injury (not above) -- Hypotension, bradycardia, decreased CO, and loss of function of the autonomic nervous system = Neurogenic shock

A nurse is caring for a pt. who is experiencing autonomic dysreflexia d/t a C5 SCI. After checking the pt.'s vital signs, which of the following actions should the nurse perform next? A. Administer nifedipine B. Place the pt. in a high-Fowler's position C. Check for urinary retention D. Check for a fecal impaction

B. Place the pt. in a high-Fowler's position This will help decrease BP ultimately reducing the risk of end-organ damage from the sudden rise in BP.

Your patient, who suffered blunt force trauma, just returned back to the ED from X-Ray which shows 2 fractured ribs. What pertinent assessment should you have already done or will you ensure you do? A. Complete a thorough neurological assessment B. Ask when their last meal was C. Auscultate the lung sounds D. Ensuring the head and neck are immobilized

C. Auscultate the lung sounds We r worried about pneumothorax or hemathorax

A nurse is assessing a client who has a high-thoracic SCI. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? A. Flushing of the lower extremeties B. Hypotension C. Tachycardia D. Report of a headache?

D. Report of a headache Manifestations of autonomic dysreflexia include hypertension, bradycardia, and flushing above the level of injury.

A pt. presents with muscular flaccidity, lack of sensation, and absent reflexes. What should the nurse suspect this pt. is experiencing?

Spinal shock

A construction worker comes to the ED with active bleeding from the R hand. A puncture wound is present. What order should the emergency nurse anticipate?

Tetanus vaccine. This human probs drilled a nail thru their hand

A nurse is caring for a patient who is wearing a halo fixator. Which of the following interventions should the nurse implement? SATA. a. Monitor the patient's vital signs q4h b. Monitor the patient's pin sites for loosening c. Hold the halo device when turning the patient d. Check the patient's skin to ensure the jacket is not applying pressure e. Adjust the screws holding the patient's halo device in place to ensure a proper fit

a. Monitor the patient's vital signs q4h b. Monitor the patient's pin sites for loosening d. Check the patient's skin to ensure the jacket is not applying pressure The RN should never hold/pull on the halo device to turn/reposition the pt. This can cause misalignment and loosen screws.

What is the result of initial trauma and usually permanent? a. Primary injury b. Secondary injury c. Complete SCI d. Incomplete SCI

a. Primary injury Secondary injury results from SCI and includes edema and hemorrhage. Complete SCI is the loss of sensory and voluntary motor communication.

The triage nurse in the ED is prioritizing care of the following patients. Which pt. takes priority? a. 2 year old female involved in a MVA with abrasions to the back of the neck b. 18 year old male with a GSW to the L great toe and a resting HR of 110 bpm c. 75 year old female with a broken hip d/t a recent fall at home d. 35 year old female involved in a MVA with a compound fracture of the femur and a cap refill of 5 secs

d. 35 year old female involved in a MVA with a compound fracture of the femur and a cap refill of 5 secs The pt. presents with life or limb pain

A nurse in the ED has assessed a patient's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? a. Question the patient's coworkers about the mechanism of injury b. Check the patient's pupils for equality and reaction to light c. Measure the client's alertness using the Glasgow Come Scale d. Immobilize the client's cervical spine

d. Immobilize the client's cervical spine

A nurse is assessing a pt. who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? a. Flushing of the lower extremities b. Hypotension c. Tachycardia d. Report of a headache

d. Report of a headache Manifestations of autonomic dysreflexia include flushing ABOVE level of injury, HYPERtension and BRADYcardia