med surg test 4

The primary priority for the critical care nurse with regard to the trauma patient is which of the following?

Provide adequate oxygenation and tissue perfusion.

In a patient with increased intracranial pressure (ICP), which of the following cranial nerves would be assessed for consensual light response, elevation of the eyelids, and eye movement?

III, IV, VI

What is the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment on increased intracranial pressure (ICP)?

Lowering ICP by facilitating venous drainage and decreasing venous obstruction.

Poor patient outcomes after a traumatic injury are associated with:

Massive transfusions of blood products.

A restrained patient's status after a motor vehicle crash includes dyspnea, dysphagia, hoarseness, and complaints of severe chest pain. Upon assessment you note that the patient has weak femoral pulses. Which of the following complications and related diagnostic test should be considered?

Aortic dissection and aortogram

Which interventions are appropriate to consider in the management of the geriatric trauma patient? (Select all that apply.)

Ask patient if they've had a fall recently. Obtain a detailed medical history. Frequently assess for signs of acute delirium. obtain detailed list of meds.

Which statements related to the management of unstable angina are true? (Select all that apply.)

Calcium channel blockers help to reduce symptoms. Aspirin is given at the onset of each chest pain episode. Early revascularization may be helpful.

The nurse is caring for a patient with a ruptured cerebral aneurysm. During initial assessment, the nurse notes that the cerebrospinal fluid draining into a ventriculostomy system is blood tinged. What is the best interpretation of this finding by the nurse?

Cerebral aneurysms commonly rupture in the subarachnoid space.

The nurse is managing the blood pressure of a patient with a traumatic brain injury. When planning the care of this patient, which statement best represents appropriate blood pressure management?

Cerebral perfusion pressure (CPP) should be sustained at least 70 mmHg

Which of the following statements is correct regarding burn classification? (Select all that apply.)

Deep partial-thickness injuries involve destruction of epidermis and most of the dermis. Partial-thickness burns involve injury to the dermal layer. Superficial burns involve only the epidermis.

The patient presents to the emergency department after having crushing chest pain for the past 5 hours. The ECG and laboratory work confirm suspicions of an acute myocardial infarction (AMI). Which findings would be the most conclusive that the patient is having an AMI? (Select all that apply.)

ECG changes with ST-elevation. Elevated CK-MB isoenyzmes. Elevated serum troponin levels.

In which circumstances should patients should be transferred to specialized burn center for treatment? (Select all that apply.)

Partial-thickness and full-thickness burns greater than 10% TBSA in patients over the age of 50.Burns involving the face, eyes, ears, hands, feet, perineum, major joints. Inhalation injury. Electrical burns, including lightening injury. Burn patients with concomitant trauma.

Which condition is a common cause of death after chest trauma?

Pulmonary contusion.

Spinal cord injury causes a loss of sympathetic output, resulting in distributive shock with hypotension and bradycardia. Although blood pressure may respond to fluid resuscitation, what other therapy may be required to compensate for loss of sympathetic innervation?

Vasopressors

A temporary wound cover composed of a graft of skin transplanted from another human, living or dead, is called a(n):

allograft

The initial drug recommended at the onset of acute myocardial infarction (AMI) to reduce platelet aggregation is:

aspirin

The nurse is monitoring a patient's intracranial pressure (ICP). While the nurse is providing hygiene measures, she observes that the ICP reading is sustained at 18 mm Hg. What is the priority nursing action?

cease stimulating the patient

Herniation syndromes can be life-threatening situations. Which syndrome causes the supratentorial contents to shift downward and compress vital centers of the brainstem?

central herniation

Angiotensin-converting enzymes inhibitors (ACE inhibitors) should be started within 24 hours of acute myocardial infarction (AMI) to reduce the incidence of:

myocardial remodeling

The patient, who is being treated for hypercholesterolemia, complains of hot flashes and a metallic taste in the mouth. These are common side effects of:

nicotinic acid

A patient is complaining of midsternal chest discomfort radiating down the right arm. The discomfort has been present for about 5 minutes. The patient is also asthmatic and allergic to calcium channel blockers. The medication of choice for this patient at this time is:

nitroglucerin subligual

Which statements best represent optimal fluid administration for the management of increased intracranial pressure? (Select all that apply.)

normal saline (0.9%0 is recommended for fluid volume resuscitation. hypotonic solutions are avoided to prevent an increase in cerebral edema.

The nurse is preparing to admit a patient from the ED who has sustained a complete spinal cord lesion at the C5 level. When planning the patient's care, which nursing intervention is most important?

perform hourly incentive spirometry

A 72-year-old patient fractured his pelvis in a motor vehicle crash 2 days ago. He suddenly becomes anxious and short of breath. His respiratory rate is 34 breaths per minute, and he is complaining of midsternal chest pain. His oxygen saturation drops to 75%. You suspect:

pulmonary embolus

The most crucial phase of treatment in burn care is during the:

resuscitative phase

Prevention of hypothermia is crucial in caring for trauma patients. Which treatments are appropriate for preventing hypothermia? (Select all that apply.)

Cover with external warming device. warm fluids and blood products before or during administration. Warm the room.

Which of the following statements are true regarding chemical injuries? (Select all that apply.)

Systemic effects such as CNS depression, pulmonary edema, and hypotension may occur. Tissue damage continues until the chemical is completely removed or neutralized. Depth of tissue injury is greatest from alkalies.

To maintain the patient's airway, which interventions are appropriate to implement with a trauma patient who sustained a spinal cord injury? (Select all that apply.)

avoid hyperextension of the neck. observe respiratory pattern. observe depth of ventilation. maintain complete spinal immobilization.

Autonomic dysreflexia is characterized by an exaggerated response of the sympathetic nervous system to a variety of stimuli. Common causes of autonomic dysreflexia include: (Select all that apply.)

bladder distention, fecal impaction

A trauma patient with a fractured forearm complains of extreme, throbbing pain at the fracture site and paresthesia in the fingers. Upon further assessment, you note that the forearm is extremely edematous and you are now having difficulty palpating a radial pulse. You notify the physician immediately because you suspect:

compartment syndrome

A 55-year-old trauma patient hit the steering wheel and has a cardiac contusion. Which are potential complications of the injury? (Select all that apply.)

dysrhythmias, hypotension, myocardial ischemia

Your patient was a passenger in a motor vehicle crash yesterday and suffered an open fracture of the femur. His condition was stable until an hour ago, when he began to complain of shortness of breath. His heart rate is 104 beats/min, respiratory rate is 30 breaths/min, BP is 90/60 mm Hg, and temperature is now 38.4° C. You suspect that he:

has a fat embolism

A 67-year-old female is admitted to the emergency department complaining of mid-back pain and shortness of breath for the preceding 2 hours. She also complains of nausea and states that she vomited twice before coming to the hospital. She denies any chest discomfort or arm pain. The presenting symptoms suggest that this patient may be:

having a MI

An adult patient suffered an anterior wall myocardial infarction (MI) 4 days ago. Today the patient is experiencing dyspnea and sitting straight up in bed. The nurse's assessment includes bibasilar crackles, an S3 heart sound with a heart rate of 125 beats/min. What condition are these signs and symptoms consistent with?

heart failure

Under normal circumstances the cerebral vasculature exhibits pressure and chemical autoregulation. What happens when autoregulation is lost?

hypertension increases cerebral blood flow.

A patient has sustained deep partial-thickness and full-thickness burns over 60% of her body. Shortly after admission, her blood pressure drops rapidly to a systolic pressure of 70 mm Hg. You know this is primarily due to:

hypovolemic shock

Ischemia to the gastrointestinal system may be caused by redistribution of blood to the brain and heart. The potential physiological effect of this is:

ileus

Which of the following are common complications of burn patients? (Select all that apply.)

immunosuppression, paralytic ileus, stress ulcer.

All burn patients are at increased risk for acute respiratory distress syndrome (ARDS) due to:

increased capillary permeability

The nurse is assessing a patient for suspected alcohol withdrawal and identifies which signs and symptoms as suspicious? (Select all that apply.)

irritable, confused, hallucinations. nausea, vomiting, diarrhea. seizures.

Burn injury severity is determined not only by the type of burn injury but also by: (Select all that apply.)

mechanism of burn injury, patient age, preexisting health status, related injuries.

Immediate interventions in the treatment of a patient with burns from tar include which of the following? (Select all that apply.)

remove clothing that has been in contact with the tar.

A hallmark finding suggesting burn injury below the glottis is:

soot particles in lung secretions

The trauma patient presenting with left lower rib fractures develops left upper quadrant tenderness, hypotension, and referred pain to the left shoulder.

splenic injury (test 5)

A major complication of an electrical burn injury is acute kidney injury caused by:

the release of myoglobin that can cause acute kidney injury

The nurse is caring for a patient with an assessed Glasgow Coma Scale score of 3. What is the best understanding of this finding?

there is impairment of the reticular activating system (RAS), resulting in coma.

The most sensitive cardiac enzyme to assess myocardial necrosis is:

troponin I