MDC4 Final Exam -QUESTIONS WITH COMPLETE SOLUTIONS., Exams of Nursing

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MDC4 Final Exam -QUESTIONS WITH COMPLETE SOLUTIONS.

What does triaging do? - Correct answers acts as gatekeeper helps prioritize patient care based on illness and severity level According to triage, what patients would be seen firtst - Correct answers highest acuity patients will receive quickest intervention (Most ill/severe will get seen first) What is a good model for triaging patients? - Correct answers ABCs Is hospital triaging the same as mass casualty triaging? - Correct answers NO Which triage situation uses tags? - Correct answers mass casualties what are the categories of triage? - Correct answers - emergent

• urgent
• nonurgent
• primary survey what classifies a patient as emergent according to triage - Correct answers - life threatening injuries
• needs immediate treatment

what patient conditions warrant an emergent status of triage - Correct answers - respiratory distress

• chest pain with diaphoresis
• stroke
• active hemorrhage
• unstable vitals what classifies a patient as urgent according to triage - Correct answers patient should be treated quickly but there is not and immediate threat to life what patient conditions warrant an urgent status for triage - Correct answers - severe abdominal pain
• renal colic
• displaced multiple fractures
• new onset of respiratory infection (pneumonia) what classifies a patient as nonurgent according to triage - Correct answers patient can wait several hours without a risk to life what patient conditions warrant a nonurgent status for triage - Correct answers - skin rash
• strains/sprains
• colds
• simple fracture

what is a primary survey that should be performed while triaging? - Correct answers ABCDE what does ABCDE stand for in triaging patients - Correct answers A: Airway/cervical spine B: Breathing C: Circulation D: Disability E: Exposure what does the "A" refer to in ABCDE - Correct answers airway, cervical spine

• patent airway
• immobilize spine **do NOT move patient what does the "B" refer to in ABCDE - Correct answers breathing
• assess sounds
• assess chest wall movement what does the "C" refer to in ABCDE - Correct answers circulation

• vitals (BP and pulse)
• maintain vascular access
• stop any bleeding what does the "D" refer to in ABCDE - Correct answers disability *LOC what does the "E" refer to in ABCDE - Correct answers exposure
• get clothes off
• use blankets to prevent hypothermia what is the one exception to ABCDE? - Correct answers in excessive bleeding, you would prioritize "C" before "AB" what is a secondary survey? - Correct answers comprehensive head to toe assessment if warranted during the secondary survey, what would a nurse likely do? - Correct answers - insert NG tube
• insert catheter
• prep for diagnostics what does drowning lead to? - Correct answers leads to loss of surfactant in lungs which causes alveolar collapse and pulmonary edema

is dehydration common in heat exhaustion? - Correct answers YES what can major diaphoresis cause? - Correct answers severe dehydration and hyponatremia if heat exhaustion goes untreated, what can it cause? - Correct answers heat stroke what are the s/s of heat exhaustion - Correct answers -dehydration -decrease in blood volume -decrease in BP -tachycardia what is the first intervention for a person expected to have heat exhaustion? - Correct answers stop their physical activity and transfer to a cool place what is the quickest way to reduce someone's temperature? - Correct answers - remove clothing

• remove bed linen what interventions are there for cooling patients down? - Correct answers - cold pack on the neck, chest, abdomen, and groin
• soak in cool water

when rehydrating someone with heat exhaustion, should you use water or a sports drink/oral reydration solution? - Correct answers Sports drink/oral hydration solution why is a sports drink better at rehydrating patients with heat exhaustion? - Correct answers plain water can worsen sodium deficits nursing care for patients hospitalized with heat exhaustion - Correct answers - monitor vitals

• administer .9% NS in N/V is present
• draw labs to check electrolytes how is heat stroke defined? - Correct answers body temperature greater than 104F T/F: heat stroke is a medical emergency - Correct answers TRUE T/F: if heat stroke is left untreated it becomes fatal - Correct answers TRUE s/s of heat stroke - Correct answers - tachycardia
• hallucinations
• irregular pulse
• decreased urin output
• hot and dry skin nursing care for heat stroke - Correct answers - 02 and .9% NS via IV

• continuous cooling, IVF, and cooling blankets. when should continuous cooling, IVF, and cooling blankets be stopped? - Correct answers when core temperature reaches 102F what should you do if your patient is shivering while being cooled from heat stroke? - Correct answers administer benzos because they provide sedation, control convulsions, and control shivering what should you NOT administer for a person with a high body temperature - Correct answers - aspirin
• antipyretics at what temperature does hypothermia occur? - Correct answers less than 95F nursing care for hypothermia - Correct answers - find shelter away from cold
• remove wet clothing
• monitor for cardio issues, ARDS, pneumonia
• focus on rewarming slowly in hypothermia, why should cardo issues be monitored? - Correct answers dysrhythmias could result from lactic acid build up what is frostbite - Correct answers freezing of body tissue

how many degrees of frostbite are there? - Correct answers 4 what happens with 1st degree frostbite? - Correct answers hyperemia and edema (hyperemia: increased blood flow) what happens with 2nd degree frostbite? - Correct answers - red area

• blisters with clear/milky fluid
• partial thickness necrosis what happens with 3rd degree frostbite - Correct answers - small blisters with dark fluid
• body is cold, numb, blue/red, and NO blanching what happens with 4th degree frostbite? - Correct answers - NO blisters or edema
• numb, cold, bloodless
• in muscle and bone what happens when frostbite reaches the muscle and bone? - Correct answers gangrene (4th degree frostbite)

how is a person warmed after frostbite? - Correct answers rapid rewarming with a water bath that's temperature is 104-108F how is a frostbit injury handled after rewarming has taken place? - Correct answers injury should be handled above heart level nursing care of frostbite - Correct answers - pain control with analgesics and IV rehydration

• loose, non adherent sterile dressings what pain medication should be used for frostbite? - Correct answers IV opiates T/F: for a person with frostbite, the nurse should tightly wrap the patients wound - Correct answers FALSE **compression should be avoided what are arthropods - Correct answers - spiders
• scorpions
• bees
• wasps nursing care for a patient injured by an arthropod - Correct answers - remove stinger
• cold compress

• Epi pen and oxygen for anaphylaxis what is affected by a lightning injury? - Correct answers heart and CNS who is most at risk for a lightning injury - Correct answers young adult males what nursing care is needed for a lightning injury - Correct answers - immediate CPR
• ECG
• CT
• tetanus prophylaxis what system is used during a mass casualty to sort patients into priority of care? - Correct answers tag system what information do you write on the triage tags? - Correct answers - color/priority
• age/DOB (identifying characteristics)
• treatment and meds already given
• next of kin what is the color system for triage tagging - Correct answers - green
• yellow
• red
• black

what does the color green mean in triage? - Correct answers non-urgent/walking, talking what does yellow mean in triage - Correct answers urgent but not life threatening what does the red tag mean in triage - Correct answers emergent could die if not treatment but have better odds what does black mean in triage - Correct answers do not attempt to treat them because their injuries are too extensive and will die regardless interventions to manage stress - Correct answers - 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 MRC - Correct answers Medical Reserve Corps

why is MRC a thing? - Correct answers Created for volunteers in the community who want to donate their time ad expertise to prepare for and respond to emergencies on a local scale DMAT - Correct answers Disaster Medical Assistance Team what does DMAT do - Correct answers they are federal employees who make up a medical relief team made up of civilians who's license is valid in all states when working how can a person be prepared for disasters - Correct answers have a go bag with personal readiness supplies **should be enough for three days at least what is an internal disaster - Correct answers anything impacting inside the hospital examples of an internal disaster - Correct answers - fire

• water pipe burst
• power outage
• shooting at Seattle Grace what is an external disaster - Correct answers A disaster that occurs in the community and may be natural, manmade, or terror-induced

examples of external disasters - Correct answers - earthquake

• flood
• car pile up
• ferry boat crash What is the most common type of dementia? - Correct answers Alzheimer's disease Is Alzheimer's reversible? - Correct answers No What is the etiology of Alzheimer's? - Correct answers Unknown Alzheimer's is the result of? - Correct answers changes in personality, memory, and/or judgement What are risk factors for Alzheimer's? - Correct answers * 65+ years

• female
• head injury
• APOE gene what is the patho of Alzheimer's - Correct answers plaques, tangles, degeneration of neurons How is Alzheimer's diagnosed? - Correct answers biopsy at autopsy is the only definitive way but dementia can be ruled out with CT, labs, UA, and MRI

Early s/s of Alzheimer's Disease - Correct answers - decreased short term memory

• decreased sense of smell
• misplaced items Middle s/s of Alzheimer's Disease - Correct answers - wander
• agitated
• incontinent
• money issues late s/s of Alzheimer's disease - Correct answers - bed ridden
• agnosia (inability to recognize objects, people, or sounds) Medications used for Alzheimer's - Correct answers Cholinesterase inhibitors
  • slow breakdown of Ach
  • Donepezil and Rivastigimine NMDA receptor antagonists
  • block excess amounts of glutamate
  • Memantine Nursing care for Alzheimer's - Correct answers - safe environment (#1) good lighting, no clutter
• stick with a routine

• offer walks, exercise
• reduce distractions
• avoid use of restraints What is Parkinson's Disease - Correct answers Movement disorder caused by the death of cells that generate dopamine in the basal ganglia and substantial nigra. Low levels of dopamine and high levels of Ach How does Parkinson's progress? - Correct answers slowly, but will eventually lead to disability How is parkinson's diagnosed - Correct answers history and s/s s/s of parkinsons - Correct answers - tremors
• muscle rigidity
• mak like facial expression
• bradykinesia
• shuffling gait
• cogwheel rigidity in limbs
• propulsive gait (head and neck forward, back is slouched) nursing care for parkinson's - Correct answers - safe environment
• sit up when eating, thick liquids

• encourage ROM and exercise Medication for Parkinson's - Correct answers - 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 What are headaches? - Correct answers vasodilation of blood vessels in the brain What causes headaches - Correct answers genetics, stress, hormones What can trigger a headache? - Correct answers coffee, yogurt, alcohol, MSG, marinated foods s/s of headache - Correct answers head pain for 4-72 hours, N/V, unilateral pain, may come with aura what are cluster headaches? - Correct answers happen at night, stuffy nose treatment of headache - Correct answers Prophylactic = propranolol Mild = NSAID Severe = sumatriptan

• ergotamine tartrate
• 6 tabs in 1 day
• take as soon as pain starts
• MOA = constricts cerebral blood vessels What is increased ICP made of? - Correct answers CSF, blood, brain what causes increased ICP - Correct answers infection, trauma, increased CSF, hemorrhage, tumors s/s of increased ICP - Correct answers MIND CRUSH M: mental status change (early sign) = decreased LOC, irritable, confusion I: irregular breathing (late sighn) = Cheyene Stokes N: nerve damage to eye = pupil changes D: decerebrate (limbs out) and decorticate (limbs to core) posturing C: cushing's triad (late) = HTN + brady + wide pule pressure R: reflux - N/V U: unconscious S: seizures H: headaches Nursing care for Increased ICP - Correct answers PRESS

P: position HOB @ 30 degrees and make sure body's midline (no flexion of neck or hips) R: respiratory we want to prevent hypercapnia by hyperventilating (limit suctioning) E: elevated temp - prevent it! S: system checks = neuro checks S: straining things - avoid it (no lifting, blowing nose, cough/sneeze) Additional Nursing care measures for ICP - Correct answers - turn down the lights

• no TV or noise
• put sign on door telling visitors to see nurse first What do you NOT do when someone has increased ICP? - Correct answers Lumbar Puncture What is the Glasgow Coma Scale? - Correct answers -A brain injury severity scale that assesses depth and duration of impaired consciousness and coma. what 3 areas make up the Glasgow coma scale? - Correct answers - eyes score 1-
• verbal score 1-
• motor score 1- Total score 3-15 **lower the score = more severe injury/status

Eyes for Glasgow Coma Scale - Correct answers ESPN E - eyes open spontaneously (4) S - sound (3) P - pain (2) N - not open (1) Verbal for Glasgow coma scale - Correct answers Our Country WIN O: oriented (5) C: confusion (4) W: words are inappropriate (3) I: incomprehensible sounds (2) N: nothing (1) Motor for Glasgow coma scale - Correct answers Can't Live Without FANs C: commands followed (6) L: localize to pain (5) W: withdrawal from pain (4) F: flexion - decorticate posturing (3) A: abnormal extension-decerebrate (2) N: nothing (1)

what are seizure - Correct answers abnormal and increase in firing of neurons what is epilepsy - Correct answers chronic seizures what triggers seizures - Correct answers stress, fatigue, coffee what are risk factors for seizures - Correct answers infection, trauma, fever, withdrawal, imbalances How do you diagnose siezures - Correct answers EEG (wash hair prior) Seizure Precautions - Correct answers - padded bed rails

• O2 and suction at bedside
• IV access
• lowest bed setting Types of siezures - Correct answers absence, atonic, tonic clonic, status epilepticus Absence Seizures - Correct answers - day dreaming
• LOC for a few seconds
• s/s = pick at clothes, lip smack, blank stare

Atonic Seizures - Correct answers loss of muscle tone - fall Tonic Clonic seizure - Correct answers - tonic = stiffening

• clonic = rhythmic jerking
• postictal phase = coming back to - confused/sleepy Status Epilepticus - Correct answers - medical emergency!
• 1 seizure that lasts > 5 mins
• repeat of seizure w/in 30 min nursing care during siezure - Correct answers - turn patient on left side (#1)
• loosen restrictive clothing
• note onset and duration
• do NOT insert anything by mouth Nursing care after seizure - Correct answers - take vitals
• perform neuro checks
• determine what trigger was
• maintain left lying position Treatment of seizures - Correct answers Phenytoin
  • narrow range (10-20), s/s= gingival hyperplasia Valproic acid

• s/s = hepatotoxic Carbamazepine
• can cause a rash (Steven Johnson syndrome) Education for Seizures and Seizure treatment - Correct answers - medication compliance (abrupt withdrawal = rebound seizures)
• do not drive
• wear medical alert bracelet surgical treatment of seizure - Correct answers - vagal nerve stimulator
• craniotomy What is encephalitis? - Correct answers infection & inflammation of the brain tissue ***life threatening How is encephalitis diagnosed? - Correct answers CSF analysis or EEG What are the s/s of encephalitis? - Correct answers stiff neck, n/v, fever What can encephalitis increase risk of? - Correct answers increased ICP Nursing care for encephalitis - Correct answers - turn down lights and noise

• keep midline and HOB @ 30 degrees
• avoid straining activities What is meningitis - Correct answers inflammation of meninges (around brain and spinal cord) what are the two main types of meningitis - Correct answers 1. viral - more common

2. bacterial - cause is step Prevention of meningitis - Correct answers vaccination

• Hib for baby
• MCV4 for teens Diagnosis of meningitis - Correct answers CSF analysis What does CSF analysis look like for viral meningitis? - Correct answers clear, increased wbc and protein what does CSF analysis look like for bacterial meningitis - Correct answers cloudy, decreased glucose, increased wbc, and protein s/s of meningitis - Correct answers nuchal rigidity, n/v, photophobia, Brudzinski's sign, Kernig's sign

What is Brudzinski's sign? - Correct answers After forced flexion of the neck there is a reflex flexion of the hip and knee and abduction of the leg. What is Kernig's sign? - Correct answers After flexing the hip and knee at 90 degree angles, pain and resistance are noted. Nursing care for Meningitis - Correct answers - 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 What is MS? - Correct answers Autoimmune disease with chronic inflammation and no cure; just periods of relapse and remition what is patho of MS - Correct answers - body attacking its own myelin sheath what causes MS - Correct answers genetic, autoimmune, infection what are risk factors of MS - Correct answers female, white, 20-50 y/o diagnosis of MS - Correct answers no 100% way

- MRI

• CSF analysis (increased WBC, proteins, IgG) S/S of MS - Correct answers - muscle weakness
• intention tremors
• tinnitus
• vision (diplopia, nystagmus) Nursing care for MS - Correct answers - protect from injury
• allow for periods of rest
• help manage stress b/c this can lead to relapse/remit Meds for MS - Correct answers -Immunomodulators, immunosuppressants (decreased inflammation, increase infection)
• muscle relaxant = baclofen what is Autonomic dysreflexia - Correct answers Firing of SNS with no PNS response what injury causes autonomic dysreflexia? - Correct answers injury above T6 what causes autonomic dysreflexia? - Correct answers - bowel, bladder, breakdown of skin s/s of autonomic dysreflexia - Correct answers - severe htn