Semester 4 Unit 2, Study

Increased intracranial pressure disrupts neurons and neurotransmitters,

resulting in faulty impulse transmission and an altered level of consciousness.

Opisthotonos

tetanic spasm in which the head and heels are bent backward and the body is bowed forward; it is associated with tetanus, strychnine poisoning, rabies, and severe meningitis.

Beta-blockers like atenolol should not be taken at night because

the blood pressure usually decreases when sleeping. This medication blocks beta-adrenergic receptors in the heart, which ultimately lowers the blood pressure.

Rapid-sequence intubation is preferred for securing an unprotected airway in the emergency Deptartment.

use of sedation with midazlopam, anesthesia with etomidate or Amidate, and paralysis with succinylcholine or Anectine.

Stress is associated

with illnesses such as heart disease, cancer, and gastrointestinal disorders.

What is A V P U?

A = Alert, V = responsive to voice, P = responsive to pain, U = unresponsive

After counseling an older widowed client, a nurse concludes that the grieving process has been successfully completed when the client does what?

A healthy resolution helps the person move away from the old, safe, familiar relationship to establish new ones.

Primary Survey Breathing Interventions

Oxygen non-rebreather mask, ventilate with bag-valve-mask with 100% O2. Prepare to intubate in severe respiratory distress or arrest. Available suction, for absent lung sounds prepare thoracostomy needle and chest tubes.

Decerebrate positioning

Decerebrate posturing includes rigid extension and pronation of the arms and legs; it is associated with dysfunction at the level of the midbrain.

Primary Survey circulation Assessment

Check for carotid and femoral pulses, peripheral pulses, palpate pulse for rate and quality, check capillary refill, assess skin color, temperature, and moisture.

In ARDS, the sputum is usually

Frothy

A nurse is caring for an anxious, fearful client. Which client response indicates sympathetic nervous system control?

The sympathetic nervous system constricts the smooth muscle of blood vessels in the skin when a person is under stress, thereby causing skin pallor.

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance?

Suction as needed. Rationale: The nurse should observe the client's need for tracheal/oral/nasal suctioning every two hours

While receiving a blood transfusion, a client develops flank pain, chills, and fever. What type of transfusion reaction does the nurse conclude that the client probably is experiencing?

A hemolytic transfusion reaction results from a recipient's antibodies that are incompatible with transfused red blood cells; it is called a type II hypersensitivity.

Statuatory rape

A rape that occurs when the assailant is above 18 years of age and the victim is under 18 years of age is referred to as statutory rape.

The nurse is assessing an elderly male. Which finding is seen with aging?

A reduction in the size of the testes is a characteristic of aging.

Which drug does the nurse anticipate to be prescribed to a client seeking treatment for infertility?

Clomiphene causes the maturation of ovarian follicles, which leads to ovulation. This drug is used to promote fertility.

How often should the nurse check ventilation settings?

Once each shift.

A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by doing what?

Opening collapsed alveoli and keeping them open

Orthotonos Positioning

Orthotonos is a tetanic spasm marked by rigidity of the body with the arms and legs in extension in a straight line; it is associated with tetanus or strychnine poisoning.

Mannitol is a

Osmotic diuretic

Primary Survey Breathing Assessments

Assess RRR, scan chest for paradoxic movement, note use of accessory muscles and diaphram, cyanosis in nail beds, mucous membranes, lung sounds, JVD distention and tracheal position.

Primary survey Airway and alertness assessments

Assess catastrophic external bleeding Assess alertness A V P U Assess for respiratory distress jaw thrust maneuver Assess for airway patency, loose teeth, Assess for bleeding, vomitus, edema

Primary Survey Facilitate adjuncts and family assessment

Assess final signs including S P o 2. Determine caregivers desire to be present during invasive procedures and or CPR.

Primary Survey Exposure and Environmental control Assessment

Assess full body for determination of additional or related injuries. Assess environment.

A female client reports a white, thick, odorless discharge from the vulva. Upon examination, the nurse finds that the vulva are swollen. What does the nurse suspect in the client?

Candida infection is manifested by a white, thick, odorless discharge from the vulva along with inflammation.

A nurse is preparing for an unconscious client with a head injury to be transferred from the emergency department to a neurologic trauma unit. Which nursing action is the priority?

Checking that a bag-valve mask is available during the transfer. Rationale: Checking that a bag-valve mask is available during the transfer is vital in case of respiratory distress.

Primary survey Circulation Interventions

Absent pulse, initiate CPR and ACLS measures Start 2 large bore IV's Normal saline of Lactated Ringers. Administer Blood products, Pevic splint or belt for pelvic fracture.

Which factors affect the stress that first responders feel after a mass casualty incident (MCI)? Select all that

Age, nature of the event, coping mechanisms, psychologic history

Nearly all trauma deaths occur because of

Airway obstruction, saliva, bloody secretions, vomitus, laryngeal trauma, dentures, facial trauma,fractures and the tongue can obstruct.

A clinic nurse is interviewing a client with syphilis. The nurse should ask the client about sexual contacts during which time period?

All partners within the past 90 days, or 3 months should be treated and notified.

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client?

Altered mental status RAtionale: Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome cognition and level of consciousness are reduced.

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, what does the nurse expect to identify?

Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome; cognition and level of consciousness are reduced.

Potential life threatening conditions in breathing assessment

Anaphylaxis, flail chest with pulmonary contusion, hemothorax, pneumothorax - open or tension.

A client is scheduled for an abdominal surgery. What is the priority preoperative nursing objective when caring for this client?

Anxiety experienced by a preoperative client can be a disruptive force that may affect the client's ability to cope psychologically and physiologically. Anxiety must be alleviated for other nursing measures to be effective.

An older caregiver should be assessed for caregiver burden.

Anxiety, depression, relationship tension, or health changes are indicators of caregiver burden.

A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome?

Aspirating gastric contents. Rationale: Aspirating gastric contents is a common cause of ARDS. Gastric enzymes injure alveolar-capillary membranes.

Primary Survey Disability assessment

Assess Level of consciousness ti verbak, painful stimuli. Glasgow Coma scale, P E R R L A

A woman is admitted for a hysterectomy and bilateral salpingo-oophorectomy. Which condition of the client causes the nurse to anticipate an abdominal, rather than a vaginal, hysterectomy?

Attempting to remove a uterus with large uterine fibroids vaginally can cause trauma, resulting in hemorrhage.

Interventions to Primary Survey Airway

Control bleeding, open airway, jaw-thrust maneuver, remove or suction foreign bodies, Insert oropharyngeal or nasopharyngeal airway, Rapid sequence intubation, Immobilize cervical spine.

What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply.

Crackles Atelectasis Arterial hypoxemia Severe dyspnea

A nurse in the neonatal intensive care unit is showing a mother her preterm infant for the first time. The mother immediately starts to cry and refuses to touch her baby. What does this behavior represent?

Crying in this situation is a typical response.

Decorticate Positioning

Decorticate posturing consists of adduction of the arms at the shoulders, flexion of the arms on the chest with the wrists flexed and the hands fisted, and extension and adduction of the lower extremities; it is associated with dysfunction at or above the upper brainstem.

Primary surveyresuscitation Adjuncts assessment

Determine need for additional hemodynamic measures to monitoring the patients condition.

Potential life threatening conditions in circulation assessment

Direct cardiac injury, pericadial tamponade, shock - massive burns, hypovolemia, uncontrolled external hemorrhage, hypothermia

A client is on mechanical ventilation. When condensation collects in the ventilator tubing, what should the nurse do?

Drain the fluid from the tubing. Rationale: Emptying the fluid from the tubing is necessary to prevent flooding of the trachea with fluid;

What age-related changes are associated with the female genitalia? Select all that apply.

Dry, smooth, and thin vaginal walls due to atrophy Graying and thinning pubic hair, decreased size of the labia majora and clitoris.

Primary signs and symptoms of compromised airway

Dyspnea, inability to speak, gasping breaths, foreign body in the airway, facial or neck trauma

The nurse is assessing a young client experiencing job-related pressure, who presents with recurrent G I disorders. What is the most important nursing intervention for this client?

Educate the client on managing stress.

Which recommendation should the nurse provide a client with fluid retention during pregnancy?

Elevate the lower extremities several times daily is recommended to ease dependent edema.

A client aspirates gastric contents and develops acute respiratory distress syndrome. Which phase characterized by signs of pulmonary edema and atelectasis should the nurse consider when planning care?

Exudative (injury) phase of ARDS is the early phase. Alveoli become fluid-filled with pulmonary shunting and atelectasis.

Primary surveyresuscitation Adjuncts Interventions

Facilitate Laboratory tests, continuously monitor E C G, Insert nasogastric tube or orogastric tube, monitor perfusions and ventilation, manage pain, provide emotional support to patient and caregiver, additional comfort measures.

Concerned about the growing incidences of suicides among high school students, the school nurse conducts an awareness session for parents. What should the nurse say are warning signs associated with risk for suicide? Select all that apply.

Feelings of loneliness verbalization of suicidal ideation Decrease in school performance

A client is admitted with head trauma after a fall. The client is being prepared for a supratentorial craniotomy with burr holes, and an intravenous infusion of mannitol is instituted. The nurse concludes that this medication primarily is given to do what?

Osmotic diuretics remove excessive cerebrospinal fluid, reducing intracranial pressure.

Rape is

Forced sexual intercourse that occurs by physical force or psychological coercion.

A nurse is caring for a client who has a tracheostomy tube and is on a ventilator. What must the nurse ensure about the tracheostomy tube?

Has a low-pressure cuff. Rational: A low-pressure cuff permits tidal volume to reach the lungs while preventing tracheal necrosis.

Potential life threatening conditions in disability assessment

Head Injury Stroke

How is Hepatitis B prevented?

Hepatitis B vaccine, Screening and testing blood donors, Monogamous relationship with an uninfected partner, Personal Protective Equipment when handling blood and body fluids.

clearing the throat

How can aphonia be corrected

A nurse manager determines that one of the nurses in the I C U may be experiencing burnout. What can the nurse manager do to help this nurse begin to confront the problem?

Identifying work stressors in the environment and coping strategies used and evaluating their effectiveness are the first steps.

When would inserting a nasopharyngeal airway be contraindicated?

In the event of facial trauma.

At which point can the primary survey be reorganized from A, B, C, D, etc.?

In the event of uncontrolled hemorrhage.

after effective breathing is ensured.

In trauma, Circulation is assessed

after the airway is assessed and cleared.

In trauma, breathing is assessed

after the vital signs are assessed.

In trauma, disability is assessed

sexual assault is defined as

Inappropriate touching and inappropriate sexual activity.

A client on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the client for which signs?

Increased restlessnes.

Potential life threatening conditions in airway assessment

Inhalation injury - fire vicitm Obstruction, partial or complete from tongue, foreign bodies, debris, vomitus or blood. Penetrating wounds or blunt trauma to upper airway.

A client requiring long-term ventilator management is discharged from the health care facility. Which health care setting should this client be referred to?

Intermediate care. Rationale: Intermediate care or a skilled nursing facility offers skilled care from licensed nursing staff.

Which gonadotropin-releasing hormone agonists are used to treat endometriosis? Select all that apply.

Leuprolide, or Lupron and nafarelin acetate, or Synarel are gonadotropin-releasing hormone (GnRH) agonists used to treat endometriosis.

Primary Survey Facilitate adjuncts and family Interventions

Obtain bilateral blood pressures for sustained or suspected chest trauma, hypertension/hypotension. Assign health team member to support caregivers.

Secondary Survey history

Obtain details of the incident or illness, timing injuries L O C, use neumponic SAMPLE

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome?

Positive end-expiratory pressure (PEEP). Rationale: Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation.

The nurse manager, in collaboration with other hospital management staff, conducted the same trial in another hospital, but the results were different. Which strategy?

Practice-based evidence

A client is admitted with traumatic injuries after a tornado. While performing resuscitation during the primary survey, the nurse notices a compromised airway. Which nursing intervention would be of most benefit to the client?

Preparing for endotracheal intubation and mechanical ventilation ensures airway patency during the primary survey in order to reduce the severity of airway compromise.

Primary Survey Disability Interventions

Reassess level of consciousness, mental status, Pupil size and reactivity.

Why is it important to facilitate the family presence for a trauma victim.

Reminds care team of personhood, caregivers provide comfort, serve as advocates

Primary Survey Exposure and Environmental control Interventions

Remove clothing for examination Stabilize impaled objects. Warmth with blankets, warmed IV fluids, overhead lights Maintain privacy

Pneumonic SAMPLE

S=symptoms, A=Allergies and tetanus status, M=Medication history, P-past health history, L=Last meal E= events or environment preceding the illness or injury.

Stress threatens

Stress threatens both mental health and physical well-being.

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator?

Suction PRN: The high-pressure alarm signifies increased pressure in the tubing or the respiratory tract; obstruction usually is caused by excessive secretions.

What syphilis treatment is most effective for women who are or suspect that they are pregnant?

The Centers for Disease Control and Prevention (CDC) recommend the intramuscular administration of 2.4 million units of benzathine penicillin G and screening of partners

Which characteristics does the nurse observe in a client who has secondary amenorrhea?

The client's menstrual cycle is absent three successive times after menarche. This is an indication of secondary amenorrhea.

A client that has a diagnosis of bone cancer is being prepared for the first radiation treatment. The client starts crying, stating, "I'm so discouraged." What is the nurse's best response?

The correct response focuses on the client's feelings of despair and provides the opportunity to talk about them "It must be difficult.."

In a mental health clinic a nurse is working with a client who is beginning to address effective ways to handle stressful situations. The best action to include in the plan of care is to have the client do what?

The identification of unhealthy habits or specific problems will allow the client to determine which additional coping skills need to be developed and practiced.

The first meeting of a therapy group, the members become uncomfortable. The nurse notes frequent periods of silence, tense laughter, and nervous movement in the group. What does the nurse conclude about these responses?

The members have not established trust and are hesitant to discuss problems; the behaviors observed reflect anxiety and insecurity.

Dyspnea. Rationale: Bleeding from the airway, aphonia, hoarseness, and subcutaneous emphysema are the clinical manifestations of laryngeal trauma. Maintaining a patent airway is a priority; therefore, dyspnea should be corrected to prevent life-threatening consequences

The nurse is assessing a client with a laryngeal trauma. This client presents with hemoptysis, aphonia, hoarseness, dyspnea, and subcutaneous emphysema. Which condition of the client stands first in the priority list?

A nurse is preparing a teaching plan for a client with syphilis. In which stage is syphilis not considered contagious?

The tertiary stage is noncontagious; tertiary lesions contain only small numbers of treponeme

Untreated syphilis can result in ____________________ in the pregnant woman.

Untreated syphilis can result in stillbirth, preterm birth, and birth defects.

What is dritical to do prior to performing a crichoidotomy?

Ventilate patient with 100% using non-rebreather mask.

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? Select all that apply.

Vomiting, Irritability,Decreased level of consciousness

How long will the suicide warning signs be apparent prior to the suicidal attempt or success?

Warning signs may occur at least a month before a suicide attempt.

Airway, Breathing, Circulation and Disability

What are the A,B, C, and D's of trauma?

Airway is first assessed in a client with severe trauma because inadequate oxygen supply can lead to brain injury that can progress to anoxic brain death.

Which parameter does the nurse assess first while assessing a client with severe trauma?

A rape that occurs when the assailant and victim know each other is referred to as

acquaintance rape.

Penetration, ejaculation, and the use of force are

clinical manifestations of rape.

increased intracranial pressure

compresses the brainstem, which contains the medulla, the respiratory center

Secondary dysmenorrhea is associated with a

dull, lower abdominal aching that radiates to the back and bloating.

Symptoms of prostate cancer include

dysuria, hesitancy, urinary urgency, and leaking or dribbling. PSA is a blood test used to confirm prostate cancer. An elevated level of prostatic isoenzyme of serum acid phosphatase is another indicator of prostate cancer.

If intubation is impossible due to airway obstruction

emergency crichoidotomy or tracheotomy is performed.

Primary survey

focuses on airway, breathing, circulation, disability,exposure, facilitation of adjuncts otherwise known as contacting family.

Hypoxia causes

hypotension

Suspected C-spine for patients with facial, head or neck trauma.

immobilize using C-collar and secure forehead to backboard.

Pressure on the respiratory center in the medulla results

in a decreased respiratory rate. As the intracranial pressure increases, the client may exhibit Cheyne-Stokes respirations.

Full and thorough head to toe assessment

include 12 lead ECG, insert Foley

The blood pressure will be

increased, because of pressure on the vital centers in the brain. Also.. the pulse pressure increases.

Osmotic diuretics increase the blood pressure by

increasing the fluid in the intravascular compartment.

Increasing pressure on the vital centers in the brain and irritation of cerebral tissue result in

irritability and seizures.

Gynecomastia

is a condition in which the adolescent has some degree of unilateral or bilateral breast enlargement.

When positioning trauma patients, the patient must be

log-rolled with 2 or more personnel.

Anorexia, nausea, and vomiting occur because

of pressure on the brain.