TRAUMA, BURNS, NEURO QUESTIONS - EXAM 4
The nurse is caring for several clients with burns. Which patients would most likely be at the highest rate of morbidity? SATA
- 87 year old with a partial thickness burn over the leg - A 37 year old patient with an Inhalation burn - A 44 year old patient with anterior and posterior trunk and entire right leg burns
Which of the following findings require immediate nursing interventions related to the assessment of a patient with a traumatic brain injury? SATA
- Non-reactive pupils - Respiratory rate of 10 breaths per minute - Mean arterial pressure of 48 mmHg
Increased ICP Management:
- Position to promote venous drainage → HOB 30, neutral head position, turn side to side - Suction only when needed (when O2 sat drops because of ↑ respiratory secretions) → preoxygenate before, limit to 10 seconds Assessment: Optic & oculomotor nerve → papilledema, unequal pupils Cushing's triad → widened pulse pressure (↑ BP), ↑ HR, ↓ RR
A patient who has sustained a head injury in a MVC has a baseline GCS score of 14. The nurse recognizes signs of increasing ICP on the basis of what assessment findings?
-increased systolic BP (severe HTN) -Bradycardia (decreased pulse) -Widening pulse pressure
The primary care provider has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The orders are for 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/hour for 23 hours. What is the total 24-hour dose for the 70-kg patient?
10,794
Treatment and/or prevention of rhabdomyolysis in at-risk patients include aggressive fluid resuscitation to achieve how much urine output?
100 ml/hr
CPP normal range
60-100 mm Hg
Parkland formula, 75 kg partial thickness anterior trunk and both arms, what is the fluid rate?
675 in the first 8 hours 338 in the second 16 hours
A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mmHg, and her mean arterial pressure (MAP) is 108 mmHg. What is the cerebral perfusion pressure?
90 mm Hg
Which patient has the greatest risk of developing acute respiratory distress syndrome (ARDS) after a traumatic injury?
A patient who has received large volumes of fluid and/or blood replacement
Four victims of an automobile crash are brought by ambulance to the emergency department (emergency department). The triage nurse determines that the victim who has the highest priority for treatment is the one with:
A sucking chest wound
Management of status epilepticus
Airway and ventilation; cardiac monitoring Hypoglycemic management (low sugars can cause seizure) Safety precautions → elevate HOB, NPO, railing pads, side lying Meds: benzos, anticonvulsants (dilantin, phenobarbital)
The wife is having cardiac arrest and the family member comes into the ER, what should you do with the family member?
Allow the man to be present and have someone stay with him, answer questions, and describe what is going on
autograft & negative pressure wound therapy
Autograft → only permanent method (human skin) For deep partial thickness & full thickness burns Negative pressure wound therapy Consistent on sponge, suction, and occlusive dressing Creates pressure to: remove edema, stimulate perfusion, provide closed system for wound healing
A 33 year old client is admitted with deep partial thickness burns over 50% body. On the 3rd day the client is tachypnea, and pulse ox of 88%. What additional findings are anticipated?
Bilateral (basilar) crackles
Fractured ribs
CXR Secondary organ injury → liver, spleen, kidney May result in flail chest → paradoxical respirations occur Tx: intubation, ventilation, & pain management
When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as:
Decorticate posturing
ICP management / meds
Diuretics → mannitol then lasix Fluid administration w/ LR/NS Temperature control → induced hypothermia; watch for shivering
Goal for increased ICP
Goal: PaO2 > 80 mm Hg, PaCO2 35-45 mm Hg
While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse?
ICP high, CPP normal
What is the correct nursing diagnosis for someone with increased ICP?
Ineffective cerebral perfusion
A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mmHg at the scene. The primary survey of this patient upon arrival to the ED:
Is done quickly in the first few minutes to get a baseline assessment and establish priorities
Considering the patients have no other issues which patient would you see first. Which client would the nurse prioritize needing immediate treatment?
Laryngeal edema and face trauma
You have a client with multiple injuries from a motor vehicle accident, the patient has a low blood pressure and a ruptured spleen. The nurse knows that glomerular filtration is dependent on:
MAP
A patient has an electrical burn, what should you do?
Monitor their cardiac rhythm (ECG)
Rhabdomyolysis
Muscle destruction causing ↑ myoglobin & potassium; tea colored urine Secondary to crush injury Can result in AKI/ARF → IV fluids titrated to achieve UO > 100 mL/hr ***
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an obstructed airway. Which action should the nurse take next?
Observe the patient's respiratory effort
Burns
Parkland Formula: 4 mL/kg x & TBSA Half of fluids in 8 hours, second half over the next 16 hours Percentage of burns: Arms = 9 each (x2) = 18 Legs = 18 each (x2) = 36 Head = 9 Genitalia = 1 Chest / back = 18 each (x2) = 36
CPP
Pressure gradient that drives O2 delivery to cerebral tissue ↑ CPP causes ↑ cerebral edema ↓ CPP means blood flow to the brain may be limited → needs fluid CPP = MAP-ICP ICP 0-15 mm Hg ICP 20 mm Hg or > for longer than 5 minutes → ↑ risk of hernia ICP monitoring if GCS of 3-8
A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding?
Rapid pulse and decreased capillary refill
The whole epidermis and parts of the dermis are burned, what type of burn classification is this?
Superficial partial thickness burn
TBI exhibiting decerebrate posturing. How would you define this?
Upper extremities pronation and extension
The patient asks the nurse if the placement of the autograft over a full-thickness burn will be the only surgical intervention needed to close the wound. The nurse's best response would be:
Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound
A patient is admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, "I have a pounding headache and I feel sick to my stomach.'' Which action should the nurse take first?
assess BP
The nurse is caring for a patient in septic shock. The nurse assesses the pt to have a BP of 105/60 mmHg, HR 110 BPM, RR 32 breaths/min, O2 95% on 45% supplemental oxygen via venturi mask, and a temperature of 102 F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first?
blood cultures
Absent breath sounds over one side after a motor vehicle accident
contact HCP
Hypovolemia / trauma
hypovolemic shock from acute blood loss (external or internal hemorrhage) VS, UO, mental status, & hemodynamics Large bore IVs → LR & NS
Which nursing assessment best describes a full thickness burn on a client?
no pain response to a pin prick
The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action?
notify HCP
Status Epilepticus →
seizures in close proximity to each other; lasting longer than 5 minutes
