PROCESS 4 Test 3

true of false; it is appropriate to remove an impaled object in a patient upon their arrival to the ED?

False; stabilize with a large bulky dressing and protect them from causing further trauma

what is the first stage in the 1 hour bundle of sepsis?

Measure lactate level (greater than 2 = need to treat)

what are signs and symptoms of shock/sepsis?

- Heart rate >90 beats/min - Tachypnea > 22/min - systolic BP <100

what are the five T's that cause PEA

- Toxins -Tamponade (cardiac) -Tension Pneumothorax - Thrombosis (coronary) - Thrombosis (pulmonary)

what body systems are usually affected first by MODS?

- cardiovascular, respiratory, renal

what are all aspects of assessing a patients airway upon the arrival to an emergency?

- determine their ability to speak - check for foreign body in airway - evaluation chest expansion

what will the nurse anticipate for a patient undergoing a secondary assessment?

- insertion of gastric tube and urinary catheter - prep for diagnostic studies - application of splints/temporary dressings

what are the five levels of the ED triage system?

- resuscitation - emergent -urgent - less urgent - non urgent

what does a patient with a pacemaker need to be educated on?

- take pulse daily -avoid direct blow to area - avoid electromagnetic fields

what are the five H's that can cause PEA

-Hypovolemia -Hypoxia -Hydrogen ion accumulating causing acidosis -Hyperkalemia or hypokalemia - hypothermia

what are parts of an assessment on a patient in an emergency that relate to disability?

-LOC (alert, verbal stimuli, painful stimuli) -check pupils

what are all aspects of assessing a patients breathing upon the arrival to an emergency?

-assess for ventilation - signs of breathing - position of trachea - color of nail bed/mucous membranes/ skin

what should a MAP be to ensure adequate cardiac output and peripheral vascular resistance?

65

what should be called if a patient stops breathing, has no heartbeat, or shows V-Fib

A Code Blue

A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent? A.A client who has a punctured femoral artery B.A client who has multiple factures C.A client who has red rash over his abdomen D.A client who reports sever flank pain radiating to the abdomen

A. A client who has a punctured femoral artery

The nurse is providing care at a large teaching hospital for a patient with critical injuries resulting from a high-speed car crash. Research is routinely conducted at the hospital. At which level of trauma center is the nurse located? A.Level 1 B.Level II C.Level III D.Level IV

A. Level 1

A nurse in the emergency department is preparing to care for a client who received multiple injuries during a fight. The nurse should plan to base his primary survey on which of the following? (Select all that apply.) A.Airway B.Cervical Spine C.Disability D.Exposure E.Urinary Output

A.Airway B.Cervical Spine C.Disability D.Exposure

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care? A.Airway protection B. Decreasing intracranial pressure C. Stabilizing cardiac arrhythmias D. Preventing musculoskeletal disability

A.Airway protection

Which statement describes the concept of scene safety in trauma situations? A.Safety is a priority issue in all settings where trauma care is provided. B.A low risk for contamination with blood and body fluids exists in trauma care. C.Emergency personnel face minimal hazards that might pose a treat to rescuers. D.Scrubs and lab jackets are appropriate attire in environments where care is provided for traumas.

A.Safety is a priority issue in all settings where trauma care is provided.

what renal effects can occur in sepsis and shock?

Acute oliguria (urine output less than 0.5ml/kg/hr for at least 2 hours

what kind of shock occurs because of a hypersensitivity reaction

Anaphylactic shock

what emergency medication is given in cases of asystole or severe bradycardia

Atropine

A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first? A.A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of < 2 seconds B. An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of < 2 seconds C. A conscious adult client who has a dislocated right shoulder, respiratory rate of 18/min, and capillary refill of < 2 seconds D. An unconscious adult client who has no respirations, capillary refill is > 2 seconds, and paramedics have already tried to reposition airway without results

B. An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of < 2 seconds

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? A. Prepare for mechanical ventilation. B.Administer oxygen via face mask C.Prepare to administer a sedative D. Assess for indications of pulmonary embolism

B.Administer oxygen via face mask

A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first? A.Apply a tourniquet just below the elbow B.Apply direct pressure over the wound. C.Clean the wound. D.Elevate the limb and apply ice.

B.Apply direct pressure over the wound.

Which statement accurately compares an emergency department with a trauma center? A.Trauma centers treat predominantly low-risk injuries. B.Emergency departments are designed to treat less severe injuries. C.Trauma centers have fewer services available than an emergency department. D.Emergency departments and trauma centers are structured to treat the same types of injuries.

B.Emergency departments are designed to treat less severe injuries.

what lab is increased in shock and indicates impaired kidney function caused by hypoperfusion as a result of severe vasoconstriction or secondary to catabolism of cells from trauma or infection

BUN

A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first? A .A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2L/min B .A toddler who has otitis media, a temperature 102.6, and purulent ear discharge. C. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough. D .An adolescent who has sickle cell disease, reports pain as 7 on a scale 0 to 10, and requests pain medication.

C. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough.

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia? A.Epinephrine B.Magnesium C.Atropine D.Sodium bicarbonate

C. Atropine- because of bradycardia

what kind of shock is caused by systolic dysfunction, diastolic dysfunction, dysrhythmias, structural anomalies, MI?

Cardiogenic

what is a more sensitive lab that indicates impaired kidney function caused by hypo perfusion as a result of severe vasoconstriction

Creatinine

Which client will the emergency nurse triage as the priority? A.21-year old with ankle fracture B.33-year old with with vomiting, flank pain, and a history of kidney stones C.49-year-old with profound weakness and 103° F fever D.59-year-old with sweating, jaw pain,, and pain in the left arm

D.59-year-old with sweating, jaw pain,, and pain in the left arm

what emergency med is given for severe hypoglycemia

Dextrose

what kind of care is focused around the critical phase of an illness or injury?

Emergency

what level of triage would a patient who needs to be seen in the next 10 minutes because their condition has the potential to become life-threatening? - they have the increased risk of death, threat to life, limb or vision

Emergent

what emergency medication is used for vasoconstriction and bronchodilation

Epinephrine

how can MAP and blood volume be increased in a person with sepsis?

Fluid replacement

what are the four main types of environmental medical emergencies?

Heat related cold related submersion bites and stings

what kind of shock occurs because of large losses of blood or volumes of fluid?

Hypovolemic

what is therapy is indicated for lethal dysrhythmias unresponsive to drug therapy. Corrects V-fib and V-tachy

Implanted cardioverter Defibrillator

what can be brought down by fluids and is one of the first things that you check in the 1 hour shock bundle?

Lactate level] - normal >0.5 - greater than 2 = treat

what level of trauma center is locating in teaching hospitals in densely populated areas and are required to conduct research?

Level 1

what level of trauma center is located in rural and remote areas and provide basic stabilization and advanced life support within resource capabilities before transferring patient to another facility

Level 4

what is also known as multiple organ dysfunction syndrome?

MODS

what is the failure of two or more organ systems in an acutely ill patient, or when two or more organ systems are unable to function well without help?

MODS

- what is a form of child abuse that is characterized by deliberate infliction or falsification of injury by the caretaker - most often done by a biological mother with some degree of medical knowledge

Munchausen Syndrome by Proxy

what level of triage requires a simple evaluation and minor management of care - can be delayed greater than two hours - ex: toothache, cold, simple laceration

Non urgent

What fluids are given to someone who is septic?

Normal saline

a history or report of injury doesn't match physical injuries, inconsistent story of how injury occurred, withdrawn, apathy, vacant stare, aggressive behavior and difficulty with relationships are all signs of what kind of abuse?

Physical Abuse

what is a biomarker that is released in response to bacterial infection

Procalcitonin

what stage of shock has a decrease in the baseline map by of more than 20 mmhg, is a life threatening emergency, and has a condition that needs to be corrected within 1 hour. Moderate acidosis, moderate hyperkalemia, and tissue ischemia are all signs of what stage of shock?

Progressive stage

what is a rhythm that appears to have electrical activity but is not sufficient to stimulate effective cardiac contractions?

Pulseless electrical activity (PEA)

what stage of shock has too little oxygen reaching tissues; cells death and tissue damage result. Patients also exhibit rapid loss of consciousness, non-palpabable pulse, cold, dusky extremities; slow, shallow respirations; unmeasurable oxygen saturation

Refectory stage

what is found in early shock secondary to hyperventilation?

Respiratory alkalosis

what level of triage would a patient suffering from cardiac arrest, respiratory arrest, or any kind of shock be considered since they need immediate treatment?

Resuscitation

what are the four components of SBAR?

S- situation B- background A- assessment R- Recommendation and request

Ischemia, infarction, infection, and injury are all causes of what?

Sepsis

what is a life threatening organ dysfunction that results from a dysregulated hosts's response to an infection that occurs as the presence of infection systematically?

Sepsis

what is also known as systemic inflammatory response syndrome?

Sepsis

what kind of shock is more common in older adults with comorbidities cuch as COPD, diabetes mellitus, infections, and chronic kidney disease?

Septic shock

Promiscuity, unusual sexual behavior, eating disorders, substance abuse, suicide threats or attempts, social isolation and signs of being withdrawn are all signs of what kind of abuse?

Sexual Abuse

hypotension, changes in body temp, cool/clammy skin, abd pain, SOB, changes in heart rate and respiratory rate are all signs of?

Shock

what is a syndrome that occurs when there is a decrease in tissue perfusion and cellular metabolism causing cells to lack the oxygen and nutrients that they need?

Shock

what type of centers are often located in an area of the hospital that is equipped to treat high risk injuries

Trauma Centers

why do potassium levels increase in late shock?

because dead cells release potassium

what is the second stage in the 1 hour bundle management of sepsis?

obtain blood cultures before administering antibiotics

what emergency medication is given for the treatment of ventricular tachycardia, V-Fib, SVT in which it stops the heart for a moment with the attempt of restarting with a normal rhythm

adenosine

what is the third & fourth stage of the 1 hour bundle management of sepsis that can be done simultaneously?

administer broad spectrum IV antibiotics and Fluids (NS)

what emergency medication is given to help convert a patient out of a dysrhythmias

amiodarone

what should be called if a patient exhibits a rapid decline in which it provides early recognition and response before a respiratory or cardiac arrest or stroke occur?

an RRT

what is the last stage of the 1 hour bundle management of sepsis?

apply vasopressors ex. norepinephrine to maintain MAP greater than 65

what are things that need to be assessed for in relation to circulation in a patient in an emergency?

assess carotid or femoral pulses, cap refill, and the skin (color, temp, moisture)

what are the three major classifications of traumatic disease?

blunt injury penetrating injury thermal injury

what is the sudden cessation of cardiac function causes most commonly by VF or ventricular asystole

cardiac arrest

what kind of abuse is non-accidental trauma that leads to physical injury, emotional harm and/or sexual violence of the child

child abuse

what stage of shock has a map decreased by 10 to 15 mm hg, urine output decreased, increased blood vessel constriction, tissue hypoxia occurs

compensatory stage

A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster? a. Members of the Federal Emergency Management agency (FEMA) b.Responding low enforcement officers c.Representatives from the American Red Cross d.Nurses and other emergency medical personnel

d.Nurses and other emergency medical personnel

what is the main aspect of the fourth principle in trauma nursing?

disposition - where do we need to discharge them too?

in what parts of shock are glucose levels increased

early stages of shock

what kind of assessment will a nurse perform if there is no trauma present in which it is a detailed review of one or more body systems according to the presenting problems?

focused assessment

what blood lab value is increased and indicates early shock because of the release of live glycogen store in response to sympathetic nervous system stimulation and cortisol

glucose

what stage of shock has the baseline map that decreases by <10 mmHg, has mild vasoconstriction, increased heart rate and is hard to dectect at this stage?

initial stage

what should also be considered when a patient comes in to the ED with a sustained blunt trauma?

internal bleeding

in what part of shock are glucose levels decreased?

late stages

what level of trauma center is located in community hospitals in which providers care to most injured patients

level 2

what level of trauma center transfers patients if needs exceed resource capabilities, in which they stabilize and then transfer patient

level 3

what occurs later in shock when lactate accumulates in blood form anaerobic metabolism

metabolic acidosis

what kind of shock occurs secondary to spinal cord injuries, spinal anesthesia, vasomotor center depression, but unlike other kinds of shock can result in bradycardia, and higher body temps then what occurs in other forms of shock?

neurogenic shock

what kind of shock occurs from a blockage of the filing or outflow of the heart leading to decreased cardiac output.

obstructive shock

what kind of therapy provides electrical stimulation to the heart to maintain adequate output?

pacemaker

what is the steps of the tiered approach for an implantable cardioverter defibrillator?

paces - cardioverter - defibrillator

what are the aspects of the second principle in trauma nursing?

primary survey and resuscitation interventions

what is the first principle in trauma nursing?

scene safety - priority concept for emergency care in all environments

what kind of assessment will be performed if trauma is present in which a brief systematic process is implemented with the goal of identifying all injuries through collection of history, head-to-toe assessment, and an inspection of posterior surfaces

secondary assessment

what are the aspects of the third principle in trauma nursing?

secondary survey and resuscitation interventions

What emergency medication is given to treat acidosis?

sodium bicarbonate

what are early signs of shock?

tachycardia, anxious appearance, confusion, tachypnea, restlessness, impaired end organ perfusion (prolonged cap refill, weak peripheral pulses) hypoactive bowel sounds

what are later signs of shock?

tachycardia, hypotension, changes in level of consciousness, changes in urine output, narrowing pulse pressure

what level of triage would a patient who needs care soon but can be seen within the next hour since they pose the risk to deteriorate or has an underlying condition such as cancer, COPD, or diabetes?

urgent

what is the fluttering of the ventricles that causes a loss of consciousness, pulselessness, and no breathing. this requires a defibrillator immediately

ventricular fibrillation