MDC4 Final Exam -QUESTIONS WITH COMPLETE SOLUTIONS LATEST UPDATE 2023T Top Ranked, Exams of Nursing

Download MDC4 Final Exam -QUESTIONS WITH COMPLETE SOLUTIONS LATEST UPDATE 2023T Top Ranked and more Exams Nursing in PDF only on Docsity! MDC4 Final Exam -QUESTIONS WITH COMPLETE SOLUTIONS LATEST UPDATE 2023T Top Ranked 1. What does triaging do? - ✔✔️*️acts as gatekeeper* helps prioritize patient care based on illness and severity level 2. According to triage, what patients would be seen firtst - ✔✔️h️ighest acuity patients will receive quickest intervention 3. (Most ill/severe will get seen first) 4. What is a good model for triaging patients? - ✔✔️A️BCs 5. Is hospital triaging the same as mass casualty triaging? - ✔✔️N️O 6. Which triage situation uses tags? - ✔✔️m️ass casualties 7. what are the categories of triage? - ✔✔️-️ emergent - urgent - nonurgent - primary survey 8. what classifies a patient as emergent according to triage - ✔✔️-️ life threatening injuries - needs immediate treatment 9. what patient conditions warrant an emergent status of triage - ✔✔️-️ respiratory distress - chest pain with diaphoresis - stroke - active hemorrhage - unstable vitals 10. what classifies a patient as urgent according to triage - ✔✔️p️atient should be treated quickly but there is not and immediate threat to life 23. what does the "C" refer to in ABCDE - ✔✔️c️irculation - vitals (BP and pulse) - maintain vascular access - stop any bleeding 24. what does the "D" refer to in ABCDE - ✔✔️d️isability 25. *LOC 26. what does the "E" refer to in ABCDE - ✔✔️e️xposure - get clothes off - use blankets to prevent hypothermia 27. what is the one exception to ABCDE? - ✔✔️i️n excessive bleeding, you would prioritize "C" before "AB" 28. what is a secondary survey? - ✔✔️c️omprehensive head to toe assessment 29. if warranted during the secondary survey, what would a nurse likely do? - ✔✔️-️ insert NG tube - insert catheter - prep for diagnostics 30. what does drowning lead to? - ✔✔️l️eads to loss of surfactant in lungs which causes alveolar collapse and pulmonary edema 31. is dehydration common in heat exhaustion? - ✔✔️Y️ES 32. what can major diaphoresis cause? - ✔✔️s️evere dehydration and hyponatremia 33. if heat exhaustion goes untreated, what can it cause? - ✔✔️h️eat stroke 34. what are the s/s of heat exhaustion - ✔✔️-️ dehydration 35. -decrease in blood volume 36. -decrease in BP 37. -tachycardia 38. what is the first intervention for a person expected to have heat exhaustion? - ✔✔️s️top their physical activity and transfer to a cool place 39. what is the quickest way to reduce someone's temperature? - ✔✔️-️ remove clothing - remove bed linen 40. what interventions are there for cooling patients down? - ✔✔️-️ cold pack on the neck, chest, abdomen, and groin - soak in cool water 41. when rehydrating someone with heat exhaustion, should you use water or a sports 52. at what temperature does hypothermia occur? - ✔✔️l️ess than 95F 53. nursing care for hypothermia - ✔✔️-️ find shelter away from cold - remove wet clothing - monitor for cardio issues, ARDS, pneumonia - focus on rewarming slowly 54. in hypothermia, why should cardo issues be monitored? - ✔✔️d️ysrhythmias could result from lactic acid build up 55. what is frostbite - ✔✔️f️reezing of body tissue 56. how many degrees of frostbite are there? - ✔✔️4️ 57. what happens with 1st degree frostbite? - ✔✔️h️yperemia and edema 58. (hyperemia: increased blood flow) 59. what happens with 2nd degree frostbite? - ✔✔️-️ red area - blisters with clear/milky fluid - partial thickness necrosis 60. what happens with 3rd degree frostbite - ✔✔️-️ small blisters with dark fluid - body is cold, numb, blue/red, and NO blanching 61. what happens with 4th degree frostbite? - ✔✔️-️ NO blisters or edema - numb, cold, bloodless - in muscle and bone 62. what happens when frostbite reaches the muscle and bone? - ✔✔️g️angrene 63. (4th degree frostbite) 64. how is a person warmed after frostbite? - ✔✔️r️apid rewarming with a water bath that's temperature is 104-108F 65. how is a frostbit injury handled after rewarming has taken place? - ✔✔️i️njury should be handled above heart level 66. nursing care of frostbite - ✔✔️-️ pain control with analgesics and IV rehydration - loose, non adherent sterile dressings 67. what pain medication should be used for frostbite? - ✔✔️I️V opiates 68. T/F: for a person with frostbite, the nurse should tightly wrap the patients wound - ✔✔️F️ALSE 69. **compression should be avoided 70. what are arthropods - ✔✔️-️ spiders 80. what does the red tag mean in triage - ✔✔️e️mergent could die if not treatment but have better odds 81. what does black mean in triage - ✔✔️d️o not attempt to treat them because their injuries are too extensive and will die regardless 82. interventions to manage stress - ✔✔️-️ develop a buddy system w/ coworker - have well balanced meals - drink alot of water - take breaks - do not exceed more than 12hrs/day - stay in touch with friends/family - crisis debriefing - take a few minutes each shift to decompress 83. MRC - ✔✔️M️edical Reserve Corps 84. why is MRC a thing? - ✔✔️C️reated for volunteers in the community who want to donate their time ad expertise to prepare for and respond to emergencies on a local scale 85. DMAT - ✔✔️D️isaster Medical Assistance Team 86. what does DMAT do - ✔✔️t️hey are federal employees who make up a medical relief team made up of civilians who's license is valid in all states when working 87. how can a person be prepared for disasters - ✔✔️h️ave a go bag with personal readiness supplies 88. **should be enough for three days at least 89. what is an internal disaster - ✔✔️a️nything impacting inside the hospital 90. examples of an internal disaster - ✔✔️-️ fire - water pipe burst - power outage - shooting at Seattle Grace 91. what is an external disaster - ✔✔️A️ disaster that occurs in the community and may be natural, manmade, or terror-induced 92. examples of external disasters - ✔✔️-️ earthquake - flood - car pile up - ferry boat crash 93. What is the most common type of dementia? - ✔✔️A️lzheimer's disease 94. Is Alzheimer's reversible? - ✔✔️N️o 95. What is the etiology of Alzheimer's? - ✔✔️U️nknown - reduce distractions - avoid use of restraints 106. What is Parkinson's Disease - ✔✔️M️ovement disorder caused by the death of cells that generate dopamine in the basal ganglia and substantial nigra. 107. Low levels of dopamine and high levels of Ach 108. How does Parkinson's progress? - ✔✔️s️lowly, but will eventually lead to disability 109. How is parkinson's diagnosed - ✔✔️h️istory and s/s 110. s/s of parkinsons - ✔✔️-️ tremors - muscle rigidity - mak like facial expression - bradykinesia - shuffling gait - cogwheel rigidity in limbs - propulsive gait (head and neck forward, back is slouched) 111. nursing care for parkinson's - ✔✔️-️ safe environment - sit up when eating, thick liquids - encourage ROM and exercise 112. Medication for Parkinson's - ✔✔️-️ Sinemet - Levodopa (increases dopamine levels in CNS) and Carbidopa (prevents levodpa breakdown) - take at same time every day - know that increased protein can alter effectiveness - Benztropine - decreases Ach levels 113. What are headaches? - ✔✔️v️asodilation of blood vessels in the brain 114. What causes headaches - ✔✔️g️enetics, stress, hormones 115. What can trigger a headache? - ✔✔️c️offee, yogurt, alcohol, MSG, marinated foods 116. s/s of headache - ✔✔️h️ead pain for 4-72 hours, N/V, unilateral pain, may come with aura 117. what are cluster headaches? - ✔✔️h️appen at night, stuffy nose 118. treatment of headache - ✔✔️P️rophylactic = propranolol 119. Mild = NSAID 120. Severe = sumatriptan - ergotamine tartrate - 6 tabs in 1 day - take as soon as pain starts - MOA = constricts cerebral blood vessels 121. What is increased ICP made of? - ✔✔️C️SF, blood, brain 143. what 3 areas make up the Glasgow coma scale? - ✔✔️-️ eyes score 1-4 - verbal score 1-5 - motor score 1-6 144. Total score 3-15 **lower the score = more severe injury/status 145. Eyes for Glasgow Coma Scale - ✔✔️E️SPN 146. E - eyes open spontaneously (4) 147. S - sound (3) 148. P - pain (2) 149. N - not open (1) 150. Verbal for Glasgow coma scale - ✔✔️O️ur Country WIN 151. O: oriented (5) 152. C: confusion (4) 153. W: words are inappropriate (3) 154. I: incomprehensible sounds (2) 155. N: nothing (1) 156. Motor for Glasgow coma scale - ✔✔️C️an't Live Without FANs 157. C: commands followed (6) 158. L: localize to pain (5) 159. W: withdrawal from pain (4) 160. F: flexion - decorticate posturing (3) 161. A: abnormal extension-decerebrate (2) 162. N: nothing (1) 163. what are seizure - ✔✔️a️bnormal and increase in firing of neurons 164. what is epilepsy - ✔✔️c️hronic seizures 165. what triggers seizures - ✔✔️s️tress, fatigue, coffee 166. what are risk factors for seizures - ✔✔️i️nfection, trauma, fever, withdrawal, imbalances 167. How do you diagnose siezures - ✔✔️E️EG (wash hair prior) 168. Seizure Precautions - ✔✔️-️ padded bed rails - O2 and suction at bedside - IV access - lowest bed setting 169. Types of siezures - ✔✔️a️bsence, atonic, tonic clonic, status epilepticus 170. Absence Seizures - ✔✔️-️ day dreaming - LOC for a few seconds - s/s = pick at clothes, lip smack, blank stare 171. Atonic Seizures - ✔✔️l️oss of muscle tone - fall 172. Tonic Clonic seizure - ✔✔️-️ tonic = stiffening 183. How is encephalitis diagnosed? - ✔✔️C️SF analysis or EEG 184. What are the s/s of encephalitis? - ✔✔️s️tiff neck, n/v, fever 185. What can encephalitis increase risk of? - ✔✔️i️ncreased ICP 186. Nursing care for encephalitis - ✔✔️-️ turn down lights and noise - keep midline and HOB @ 30 degrees - avoid straining activities 187. What is meningitis - ✔✔️i️nflammation of meninges (around brain and spinal cord) 188. what are the two main types of meningitis - ✔✔️1️. viral - more common 189. 2. bacterial - cause is step 190. Prevention of meningitis - ✔✔️v️accination - Hib for baby - MCV4 for teens 191. Diagnosis of meningitis - ✔✔️C️SF analysis 192. What does CSF analysis look like for viral meningitis? - ✔✔️c️lear, increased wbc and protein 193. what does CSF analysis look like for bacterial meningitis - ✔✔️c️loudy, decreased glucose, increased wbc, and protein 194. s/s of meningitis - ✔✔️n️uchal rigidity, n/v, photophobia, Brudzinski's sign, Kernig's sign 195. What is Brudzinski's sign? - ✔✔️A️fter forced flexion of the neck there is a reflex flexion of the hip and knee and abduction of the leg. 196. What is Kernig's sign? - ✔✔️A️fter flexing the hip and knee at 90 degree angles, pain and resistance are noted. 197. Nursing care for Meningitis - ✔✔️-️ bacterial = antibiotics - viral = acyclovir - steroids (decrease inflammation, increased infection) - prophylaxis treatment for anyone in contact/exposed - implement droplet precautions for first 24 hours of treatment - Decrease ICP risk by elevating HOB, keep body midline, avoid straining activities, turn everything down - bradycardia - headache - diaphoresis - blurry vision - facial flush above injury - pale below injury 210. nursing care for autonomic dysreflexia - ✔✔️P️revent: - bladder distention (empy it, check tubing for kinks, use bladder scanner) - bowel - check for impactation - skin breakdown - remove tight clothing 211. Detect: at risk above T6 injury, report of headache, check BP 212. Action: elevate HOB, Remove restrictive clothing, schedule bowel and bladder maintenance 213. What is true for spinal cord injury - ✔✔️t️he higher the injury, the more system affected and shorter the lifespan 214. diagnosis of spinal cord injury - ✔✔️X️-ray, CT scan, MRI 215. prevention of spinal cord injury - ✔✔️s️top drugs and alcohol 216. causes of spinal cord injury - ✔✔️t️raumatic: falls, MVA, violence 217. Non-traumatic: tumors, RA 218. Direct: fracture, hyperflexion (diving), hyperextension, penetration (GSW), axial load 219. types of spinal cord injuries - ✔✔️C️omplete: complete severed spinal cord, complete loss of function below injury 220. Incomplete: spinal cord is partially severed, partial loss of function 221. Quadriplegia - at C6 - Unable to move all 4 extremeties - MVA, fall 222. Paraplegia - below T1, paralysis of lower extremities, can be result of GSW 223. what is the main cause of death for people with spinal cord injuries - ✔✔️s️epsis, pneumonia, PE 224. Acute management of spinal cord injury - ✔✔️-️ airway and breathing - immobilize head and neck (c-collar) - determine LOC by using GCS - Aware of their deficits - anxiety and depression 238. Right-sided stroke s/s - ✔✔️-️ poor impulse control and judgement - 1 sided neglect syndrome (unaware of deficits on left side of body, big safety concern) - short attention span - proprioception (depth) issues 239. Broca's area - ✔✔️e️xpressive aphasia: unable to communicate/express back in speech 240. Wernikies aphasia - ✔✔️r️eceptive aphasia: unable to receive/understand what is being said 241. nursing care for both broca's and wernikies - ✔✔️-️ be patient - use short phrases - use gestures/point - limit distractions around 242. Treatment of stroke - ✔✔️G️eneral - anticoagulants, stool softeners, benzo's 243. Ischemic stroke aka clot - tPa = thrombolytics (must be w/in 3 hours, BP needs to be in range, neuro checks every 15 mins. NOT for bleeding, htn, >3hrs 244. Hemorrhagic stroke - only treatment is surgery (BP must be in range, NOT for someone on blood thinners (coumadin), if blood is too thin, admin fresh plasma or Vit K) 245. Nursing care for stroke - ✔✔️-️ safe environment (teach patient to scan before ambulating) - lots of eating concerns: - sit up - tuck chin - thick liquids - use dentures - no straws - take small bites - use mechanical soft diet 246. Complications of stroke: increased ICP, seizures, HTN, headach 247. Who is at risk for TBI - ✔✔️i️nfants, teens, older adults 248. how does TBI occur - ✔✔️f️alls, mva, gsw, sports 249. levels of tbi - ✔✔️m️ild - concussion 250. moderate - decreased loc 251. severe - prolonged LOC 252. types of TBI - ✔✔️-️ subdural hematoma - bleeding below dura and above arachnoid - primary: open (directly to brain) closed (fracture) - secondary - result of primary 267. can a person with flail chest recover - ✔✔️m️anagable with vigilant respiratory care 268. when is mechanical ventilation needed for a patient with flail chest - ✔✔️-️ respiratory failure - shock - severe hypoxemia and hypercarbia 269. nursing care for flail chest - ✔✔️-️ monitor ABGs - monitor vitals 270. with flail chest, what causes increase the risk of respiratory failure - ✔✔️-️ lung contusion - underlying pulmonary disease 271. how is flail chest usually stabilized - ✔✔️p️ositive pressure ventilation 272. what interventions are needed for low BP - ✔✔️-️ fluid replacement - Trendelenburg - compression stockings - medication 273. what causes a high pressure vent alarm - ✔✔️-️ thick mucus/secretions blocking the airway - coughing - biting on tube - fighting vent - wheezing - bronchospasms - pneumothorax - displaced tube - obstruction - water in vent circuit 274. what causes a low pressure vent alarm - ✔✔️-️ leak in circuit - cuff leak - patient disconnected 275. *apnea alarm* 276. possible interventions for high pressure vent alarm - ✔✔️-️ check patient first! - check all tubing is connected and not kinked - suction patient - medication for pain, anxiety, sedation - change vent settings 277. what causes increased or thick secretions/mucus in a patient who is intubated - ✔✔️n️ot enough humidity 278. possible interventions for low pressure vent alarms - ✔✔️-️ check patient first! - manually bag patient - reconnect/unkink tubing 279. nursing care of ventilated patient - ✔✔️-️ q2-4 respiratory assessment, oral care, suctioning if needed - q4 head to toe assessment and vitals - maintain head of bed 30 degrees - q2 turns 291. what does ARDS stand for - ✔✔️a️cute respiratory distress syndrome 292. what intervention is done for a healthy person who sustains an acute lung injury - ✔✔️m️echanical ventilation 293. pathophysiology of ARDS - ✔✔️i️ncreased alveolar permeability + leaking of fluid = alveolar collapse 294. what causes ARDS - ✔✔️-️ sepsis - burns - pancreatitis - transfusion - trauma - diffuse pulmonary infection - gastric aspiration - O2 toxicity - lung contusion 295. s/s of ARDS - ✔✔️-️ persistent hypoxia (even with O2 therapy) - dyspnea - decreased pulmonary compliance - non cardiac pulmonary edema 296. how to diagnose ARDS - ✔✔️-️ refractory hypoxia - chest x ray shows glossy + white out (diffuse patchy infiltrates) - normal wedge pressure - pO2/FIO2 < 200 297. phases of ARDS - ✔✔️-️injury (exudative) phase - alveolar collapse - refractory hypoxemia 298. -reparative (proliferative) phase - decreased lung compliance 299. -fibrotic phase - surfactant cells are damaged 300. assessment of patient on vent - ✔✔️-️ vitals - O2 saturation - auscultate breath sounds - pain/anxiety - tube placement - vent settings 301. nursing care for ARDS - ✔✔️-️ ET + Mechanical vent w/ PEEP or CPAP - light IV fluids, diuretics, antibiotics - start nutrition (TPN or tube feeds) 302. risk factors for pulmonary embolism (PE) - ✔✔️-️ immobile, obese, advanced age, surgery - central venous catheter, embolic event history - pregnancy, oral contraceptives, estrogen therapy - heart failure, trauma, smoker 303. assessment findings for PE - ✔✔️-️ sudden dyspnea - chest pain - feeling of impending doom - JVD - tachy - increase movement 314. medication treatment for PE - ✔✔️a️nticoagulants *initiate bleeding precautions* - heparin - watch aPTT+ platelet count - warfarin - watch PT + INR levels - antidote = vitamin K 315. fibrinolytic - thrombolytic = alteplase (tPa) 316. surgical treatment of PE - ✔✔️-️ embolectomy = removal of clot - inferior vena cava filter = temporary filter that keeps clots from getting to lungs 317. **not for patients on heparin** 318. hypovolemic shock assessment findings - ✔✔️-️ weak, thready pulse - tachy and hypo - cold clammy skin - decreased CO = decreased tissue perfusion 319. what is neurogenic shock - ✔✔️-️ Caused by spinal cord injury, usually as a result of a traumatic accident or injury - Common with T6+ - SNS disruption 320. neurogenic shock assessment findings - ✔✔️-️ hypotensive and bradycardic - warm and dry skin - hypothermia 321. neurogenic shock treatment - ✔✔️-️ establish circulatory blood volume - administer atropine for low heart rate - keep patient warm - prep to intubate 322. what is DIC - ✔✔️d️isseminated intravascular coagulation 323. what does DIC cause - ✔✔️a️bnormal coagulation involving fibrinogen - excessive clotting along with hemorrhage at the same time 324. treatment of DIC - ✔✔️-️ blood transfusion - FFP (fresh frozen plasma) - fluid replacement 325. lab values for lactate during hypovolemic shock - ✔✔️>️2 indicates shock 326. medication for hypovolemic shock - ✔✔️v️asopressors 327. what do vasopressors do - ✔✔️i️ncrease the workload of the heart 328. what does vasopressin do - ✔✔️-️ causes vasoconstriction (increase BP) - singed nasal hairs - soot in upper airway - assess sputum 345. with a superficial (1st degree) burn, what layer of skin is affected - ✔✔️e️pidermis 346. with a partial thickness (2nd degree) burn, what layer of skin is affected - ✔✔️-️ epidermis - partial dermis - hair follicles intact 347. with a full thickness (3rd degree) burn, what layer of skin is affected - ✔✔️-️ epidermis - dermis - SQ - possible muscle and bone 348. what is usually the cause of a superficial (1st degree) burn - ✔✔️-️ sunburn - UV light - flash injuries 349. what is usually the cause of a partial thickness (2nd degree) burn - ✔✔️-️ contact - flash flame to clothes - direct flame - chemicals - UVL 350. what is usually the cause of a full thickness (3rd degree) burn - ✔✔️-️ contact - flame - chemicals - electrical 351. what is the appearance of a superficial (1st degree) burn - ✔✔️-️ dry - no blisters - minimal edema - blanches 352. what is the appearance of a partial thickness (2nd degree) burn - ✔✔️b️listers - superficial: moist, blanches - deep: less moist, decreased blanching 353. what is the appearance of a full thickness (3rd degree) burn - ✔✔️-️ dry with leathery eschar - charred vessels - no blanching 354. what is the color of a superficial (1st degree) burn - ✔✔️r️ed 355. what is the color of a partial thickness (2nd degree) burn - ✔✔️-️ superficial: pink - deep: pale mottle with dull white, tan, and cherry red areas 356. what is the color of a full thickness (3rd degree) burn - ✔✔️-️ white - charred - dark tan - black - red 372. what labs are used to measure nutrition after burns - ✔✔️-️ albumin - prealbumin - total protein 373. What are the different types of shock - ✔✔️-️ cardiogenic shock - hypovolemic shock - anaphylactic shock - septic shock - neurogenic shock 374. what is cardiogenic shock due to - ✔✔️h️eart problems 375. what is hypovolemic shock cause by - ✔✔️t️oo little blood volume 376. what is anaphylactic shock caused by - ✔✔️a️llergic reaction 377. what is septic shock due to - ✔✔️i️nfection 378. what is neurogenic shock caused by - ✔✔️d️amage to the nervous system 379. When do we consider a patient a candidate for trach placement after ET intubation? - ✔✔️p️atients with respiratory failure who cannot be weaned within 7-10 days are candidates for tracheostomy. Most severely injured trauma patients requiring intubation longer than 5 days will require airway support and will benefit from early tracheostomy