Review Questions

eyes opening spontaneously is how many points on the GCS scale

4

hypovolemia is most often treated by giving

IV fluids LR hypertonic saline

Why are the manifestations of most types of shock the same despite different causes?

SNS is triggered by any type of shock and initiates stress response

describe a deep, partial-thickness burn

Second degree burn Skin red/white, blisters, swelling, dermal layer visible, moderate edema

Pain management for the burn patient is most effective when (select all that apply) a. a pain rating tool is used to monitor the patient's level of pain. b. painful dressing changes are delayed until the patient's pain is completely relieved. c. the patient is informed about and has some control over the management of the pain. d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury.

a, c, d

When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply) a. blisters. b. exposed fascia. c. exposed muscles. d. intact nerve endings. e. red, shiny, wet appearance.

a, d, e

in hypovolemia SV is

decreased

what is an expected finding of DIC?

excessive thrombosis & bleeding

3 areas tested on GCS

eyes, verbal, motor

emergency tx for a tension pneumothrorax

needle decompression

most common type of burn injury

thermal

process by which pt are assess and prioritized

triage

t/f DIC is caused by abnormal coagulation involving fibrinogen

true

A nurse is caring for a patient with multiple injuries due to trauma whose blood pressure on admission was 118/67. Fifteen minutes later, the patient's blood pressure was 162/34. Which of the following injuries does the nurse suspect based on these BP measurements? A. Neurogenic shock B. Hypovolemic shock C. Closed head injury D. Pneumothorax

C-- widening pulse pressure (ICP indication)

normal adult ICP is

5-15

what is a normal ICP

5-15 mmHg

ped pts who have s/sx shock should be started on abx within __ min

60

systemic inflammatory response syndrome (SIRS) by definition has a HR greater than ___

90

A patient is admitted after a severe burn injury and is undergoing fluid resuscitation. Which of the following is the most accurate assessment of successful fluid resuscitation? A. Urine output > 30ml/hr B. Weight gain of 1 kg in 8 hours with good capillary refill C. HR 94 bpm, BP 95/55 mmHg D. Serum potassium decrease from 5.8 mEq/L to 5.2 mEq/L

A

An ER nurse is assessing pt who has internal injuries from a car crash. Pt is disoriented to time and place, diaphoretic, and lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock? a. inc HR b. widening pulse pressure c. inc deep tendon reflexes d. SpO2 96%

A-- small preload so heart beats fast to try and spread it quicker

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is a. applying pressure garments. b. repositioning the patient every 2 hours. c. performing active ROM at least every 4 hours. d. massaging the new tissue with water-based moisturizers.

a

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for a. patency of airway. b. presence of a neck injury. c. neurologic status with the Glasgow Coma Scale. d. cerebrospinal fluid leakage from the ears or nose.

a

The injury that is least likely to result in a full-thickness burn is a. sunburn. b. scald injury. c. chemical burn. d. electrical injury.

a

To maintain a positive nitrogen balance in a major burn, the patient must a. eat a high-protein, high-carbohydrate diet. b. increase normal caloric intake by about three times. c. eat at least 1500 calories/day in small, frequent meals. d. eat a gluten-free diet for the chemical effect on nitrogen balance.

a

what are 4 actions a nurse should complete within the first hr to manage sepsis?

admin abx, admin fluid (30 ml/kg), obtain blood cultures, measure lactate cultures

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat. b. elevate the head of the bed to 30 degrees. c. maintain patient on the left side with the head supported on a pillow. d. use a continuous-rotation bed to continuously change patient position.

b

A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain. b. controlling fever with prescribed drugs and cooling techniques. c. keeping the room dark and quiet to minimize environmental stimulation. d. maintaining the patient on strict bed rest with the head of the bed slightly elevated.

b

A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to a. reapply a new dressing without disturbing the wound bed. b. observe the wound for signs of infection during dressing changes. c. apply cool compresses for pain relief in between dressing changes. d. wash the wound aggressively with soap and water three times a day.

b

Vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter. b. altering the endothelial lining of cerebral capillaries. c. leaking molecules from the intracellular fluid to the capillaries. d. altering the osmotic gradient flow into the intravascular component

b

A nurse is caring for a pt in the compensatory stage of shock. Which of the following findings should the nurse expect? a. mottled skin b. BP 115/68 c. HR 160 d. hypokalemia

b-- sympathetic nervous system is stimulated, catecholamines keep BP in normal range mottled skin- progressive HR- 100-150 would be expected hypokalemia- should see hyperkalemia

how do vasoactive meds need to be administered

central line

a hospitalized pt is found unconscious on bathroom floor. What action should be taken first

check respiratory rate

a type of burn that results in contact with acids

chemical

peripheries are ____ in a pt with cardiogenic shock

cold (not getting blood, poor circulation)

A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a. Encourage the patient to cough and auscultate the lungs again. b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas. c. Document the findings and continue to monitor the patient's breathing. d. Anticipate the need for endotracheal intubation and notify the physician.

d

A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure. b. an alteration in the production of cerebrospinal fluid. c. the loss of autoregulatory control of intracranial pressure. d. a normal balance between brain tissue, blood, and cerebrospinal fluid.

d

4 components used to classify burns

depth, TBSA, type of burn, location, PMH/age

give one type of med that can reduce preload

diuretics-- furosemide nitrates-- nitro

immediate pharm tx for anaphylactic shock

epi pen

components of a superficial- partial thickness burn

first degree burn no open skin, sunburn, blanching, red, dry, no vesicles

Discharge instructions to a parents following their child's concussion should include, "call 911 if..."

has convulsions or seizure, profuse N/V, increased sensitivity to light and/or sound

what are the 2 main components of the secondary survey

head to toe AMPLE

4 main stages of shock

initial compensatory progressive refractory/irreversible

one hr sepsis bundle includes obtaining

lactate and blood cultures

the highest trauma level a hospital can have

level I (one)

which test will the nurse administer to assess whether a person is developing post-concussion syndrome

memory test

3 main classifications of TBI

mild, moderate, severe

most common cause of cardiogenic shock

myocardial infarction (MI)

injury caused by a foreign object piercing the skin and damaging the underlying tissues is what kind of trauma

penetrating trauma

set of sx that persists for weeks following a concussion

post concussion syndrome

two late clinical signs of basilar skull fracture

raccoon eyes (eye bruising) battle sign (bruising by ears)

2 common triggers for anaphylactic shock

seasonal allergies, food, animals, medications, latex, contrast

a pt admitted with a head injury develops clear, watery nasal drainage. what should the nurse do

send a sample to the lab to see if it contains glucose

A nurse is assessing a pt's wound dressing and observes a watery red drainage. The nurse should document this as:

serosanguineous

Pt is admitted to ER following a head injury sustained in an MVA. What is nurse's first priority

stabilize cervical spine

CO= HR x ___

stroke volume (SV)

A nurse is developing a plan of care for a client who is rehabilitating from major burns. What intervention can the nurse include to provide emotional support?

talk with the client while providing wound care

t/f a concussion is a minor diffuse head injury whereas a contusion is bruising of the brain tissue in a focal area

true

t/f classic sequel of epidural hematoma is loss of consciousness at the scene, brief lucid interval, then dec LOC

true

t/f falls are the leading cause of TBI in the US

true

hypovolemic shock is a blood __ problem

volume

list 2 resp symptoms associated with anaphylactic shock

wheezing, dyspnea, stridor, edema of larynx, bronchoconstriction, rhinitis

3 components of Cushing's Triad

widening pulse pressure irregular respirations bradycardia associated with inc ICP

a burn with TBSA > than ____ requires a referral to a burn center

10%

MAP-ICP=

CPP (cerebral perfusion pressure)

A nurse is responding to a mass casualty incident. Place in order the patients to be triaged, from most important to least. A. A patient with a large scalp laceration who is walking around at the scene B. A. patient with a broken arm and no other injuries C. A patient who is scared and crying about the incident D. A patient who was killed in the accident E. A patient with a sucking chest wound who is having trouble breathing

E A B C D

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks what the procedure entails. How do you explain it?

Large incisions will be made in the eschar to improve circulation

used to determine TBSA in pediatric pt

Lund & Browder Chart

A patient is suspected of having a brain tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the a. frontal lobe. b. parietal lobe. c. occipital lobe. d. temporal lobe

a

GCS scale-- severe is

3-8

describe components of primary survey

ABCDE airway, breathing, circulation, disability/neuro, exposure

primary survey is made up of what

ABCDE airway, breathing, circulation, disability/neuro, exposure

A flight nurse arrives at the scene of a motor vehicle collision and observes the victim has had a traumatic amputation. What is the priority nursing action? A. Place the severed body party in a clean bag B. Apply pressure to the stump with sterile gauze to prevent hemorrhage C. Place the severed part in a bag and submerge the bag in ice water to preserve it.

B

A nurse in the ER is assigned 4 patients. Which patient is a priority for assessment and treatment? A. A patient with Diabetes and increased thirst with a temp of 100.6F and blood glucose of 380 mg/dL B. A patient who takes warfarin and fell from a ladder, had a brief LOC and now has a severe headache C. A patient with stable vital signs and RLQ abdominal pain D. An older patient with a swollen and deformed ankle after stepping off a curb, equal pulses in both feet

B

You are working as an ER Triage RN. As patients present for initial contact with you, who should be given the highest priority? A. A patient who fell and has wrist pain with an obvious deformity B. A patient with new-onset slurred speech and right arm weakness. C. A patient with dysuria and urinary urgency for a day with a temp of 100.4 F D. A patient with a small laceration who has not received a recent tetanus shot.

B

A patient is admitted to the ER for treatment of a severe burn. Which of the following orders would the nurse question for this patient? A. Water B. Potassium C. Lactated Ringer's D. Plasma Expanders

B-- burns usually cause hyperkalemia

A nurse is in the ER assessing a patient following a MVC. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mmHg, HR 124 bpm, Respirations of 34 breaths/min, and SaO2 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest X-ray B. Place the patient on an ECG monitor C. Administer Oxygen via a high-flow mask D. Initiate IV access

C

The nurse is assessing a patient in the ER with a traumatic head injury following a motor vehicle crash. The nurse determines that the patient has a GCS score of 8. This score is consistent with what? A. Mild head injury B. Moderate head injury C. Severe head injury

C

A 28-year-old female comes to the ER because she is involved in a house fire 35 minutes ago. She is conscious, but in significant pain. She has significant burns to her head and neck, anterior chest and abdomen, and entire right leg. Which of the following most likely represents the total percentage of her TBSA involved in the burn? A. 27 % B. 36% C. 45% D. 63%

C (head & neck- 9, anterior chest- 9, abdomen- 9, right leg- 18)

A nurse in an urgent care clinic is triaging patients. Which of the following patients should the nurse identify as the priority to be examined first? A. An adolescent patient who is confrontational has decreased reasoning and slurred speech B. A toddler with a laceration on the forehead and is screaming C. A middle-aged patient who is diaphoretic and reports epigastric pain D. A young adult with a painful sunburn over the face and arms

C (then A)-- C might have something cardiac happening

A nurse is caring for a patient who has a third-degree burn. Which of the following would the nurse expect to find when assessing the burn? (select all that apply) A. Pain B. Erythema C. Edema D. Eschar E. Fluid filled vesicles

C, D, E

An ER nurse is caring for a client who has anaphylaxis following a bee sting. Which action should the nurse take first? a. assess LOC b. administer epi c. auscultate for wheezing d. monitor for hypotension

C-- think ABCs

A patient is admitted with burns to their face, neck, anterior chest, and hands. The nurse's priority action would be? A. Cover the burned area with a sterile dressing B. Initiate IV fluid administration C. Administer pain medication as ordered D. Assess for dyspnea and stridor

D-- think ABCs then B, C, A

disorder when proteins that clot blood do not function correctly

DIC disseminated intravascular coagulation

rapid bedside US for blood around heart or abdominal organs

FAST Ultrasound focused, assessment, sonography and trauma

A nurse is caring for a client who has full-thickness burns on 75% of his body. The nurse should use which method to monitor the cardiovascular system?

Monitor pulmonary artery pressure-- (can determine changes in right & left heart pressure)

a pt reacts to nail bed pressure by folding arms to their chest-- what is Glasgow score for this?

abnormal flexion

A nurse is caring for a pt in CCU who suffered a knife wound to the chest. Pt is developing cardiac tamponade. What assessment finding should the nurse identify that supports this? a. sudden lethargy b. muffled heart sounds c. bradycardia d. flattened neck veins

b. muffled heart sounds-- build up of fluid muffles sounds

one example of obstructive shock

blood clot, cardiac tamponade, pulmonary embolism, pneumothorax, superior vena cava syndrome

injury to body by forceful impact with a dull object

blunt/non-penitrating

A patient is recovering from second- and third-degree burns over 30% of his body and the burn care team is planning for discharge. The first action the nurse should take when meeting with the patient would be to a. arrange a return-to-clinic appointment and prescription for pain medications. b. teach the patient and the caregiver proper wound care to be performed at home. c. review the patient's current health care status and readiness for discharge to home. d. give the patient written information and websites for information for burn survivors.

c

Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include a. adherence of albumin to vascular walls. b. movement of potassium into the vascular space. c. sequestering of sodium and water in interstitial fluid. d. hemolysis of red blood cells from large volumes of rapidly administered fluid.

c

Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety? a. Set hot water temperature at 140° F. b. Use only hardwired smoke detectors. c. Encourage regular home fire exit drills. d. Never permit older adults to cook unattended.

c

The nurse is alerted to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery. b. has focal symptoms of brain damage with no recollection of a head injury. c. develops decreased level of consciousness and a headache within 48 hours of a head injury. d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.

c

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. Older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale d. Patient who had a craniotomy for a brain tumor and who is now 3 days postoperative and has had continued vomiting

c

Nursing management of a patient with a brain tumor includes (select all that apply) a. discussing with the patient methods to control inappropriate behavior. b. using diversion techniques to keep the patient stimulated and motivated. c. assisting and supporting the family in understanding any changes in behavior. d. limiting self-care activities until the patient has regained maximum physical functioning. e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs.

c, e

A nurse is caring for a pt who has hypovolemic shock. Which of the following should the nurse expect as a finding? a. htn b. flushing of skin c. oliguria d. bradypnea

c-- no fluid to let go of