NSG 233 FINAL EXAM LATEST 2024 -2025: MEDICAL-SURGICAL 3NURSING STUDY GUIDE | STUDY GUIDE, Exams of Nursing

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NSG 233 FINAL EXAM LATEST 2024 - 2025:

MEDICAL-SURGICAL 3 NURSING STUDY

GUIDE | STUDY GUIDE QUESTIONS AND

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What assessment finding should the nurse document in the EMR for a client experiencing autonomic dysreflexia after a spinal cord injury? Correct Answer Severe hypertension Diaphoresis Flushing above the lesion As the nurse is turning a client with a chest tube, the tube becomes dislodged from the pleural space. What action should the nurse take first? Correct Answer Have the client exhale forcefully and tape three sides of a sterile gauze over the insertion site The nurse plans to administer a low dose prescription for dopamine (Intropin) to a client who is in septic shock. What physiological parameter should the nurse use to evaluate the therapeutic response? Correct Answer Urinary output The nurse assess a male client postoperately who has an arterial line in the raidal artery. Assessment findings include pallet, parastesia, and slow capillary refill in the clients right hand fingers. What action should the nurse take? Correct Answer Notify HCP

A male client is admitted to the cardiac intensive unit with chest pain that began twelve hours ago. The nurse recognizes increased ventricular ectopic. Based on this what action is important for the nurse to implement? Correct Answer Initiate the unit's antiarrythmic protocol if symptomatic The nurse is assessing a client who was admitted 24 hours ago to the critical care unit after a motercycle accident. Which finding requires intervention by the nurse to reduce the risk for complications related to increased ICP? Correct Answer Change of PaCo2 to 55mmHg following ventilator setting adjustment A client is recieving CPR. After asystole is confirmed in two leads and sending for the trancutaneous pacemaker, which IV med should be administered? Correct Answer Epinephrine The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow coma scale is 9. What information is most important for the nurse to determine? Correct Answer The client's previous GCS score Chest Trauma- Complications Correct Answer Flail chest is frequently a complication of blunt chest trauma, which may occur from a steering wheel injury, motor vehicle crash involving a pedestrian or cyclist, a significant fall onto the chest, or an assault with a blunt weapon. As with rib fracture, treatment of flail chest is usually supportive. Management includes providing ventilatory support, clearing secretions from the lungs, and controlling pain. For mild-to-moderate flail chest injuries, the underlying pulmonary contusion is treated by monitoring fluid intake and appropriate fluid replacement while relieving chest pain. Pulmonary physiotherapy focusing on lung volume expansion and secretion management techniques is performed. The patient is closely monitored for further respiratory compromise.

For severe flail chest injuries, ET intubation and mechanical ventilation are required to provide internal pneumatic stabilization of the flail chest and to correct abnormalities in gas exchange. Shock Fluid Correct Answer At least two large-gauge IV lines are inserted to establish access for fluid administration. Because the goal of the fluid replacement is to restore intravascular volume, it is necessary to administer fluids that will remain in the intravascular compartment to avoid fluid shifts from the intravascular compartment into the intracellular compartment. As discussed earlier, crystalloid solutions such as lactated Ringer's solution or 0.9% sodium chloride solution are commonly used to treat hypovolemic shock, as large amounts of fluid must be given to restore intravascular volume. Hypovolemic Shock Correct Answer Hypovolemic shock, the most common type of shock, is characterized by decreased intravascular volume. Body fluid is contained in the intracellular and extracellular compartments. Intracellular fluid accounts for about two thirds of the total body water. The extracellular body fluid is found in one of two compartments: intravascular (inside blood vessels) or interstitial (surrounding tissues). The volume of interstitial fluid is about three to four times that of intravascular fluid. Hypovolemic shock occurs when there is a reduction in intravascular volume by 15% to 30%, which represents an approximate loss of 750 to 1500 mL of blood in a 70-kg (154-lb) person Cardiogenic Shock S&S Correct Answer Cardiogenic shock occurs when the heart's ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and the tissues. In cardiogenic shock, cardiac output, which is a function of both stroke volume and heart rate, is compromised. Patients in cardiogenic shock may experience the pain of angina,

develop arrhythmias, complain of fatigue, express feelings of doom, and show signs of hemodynamic instability. Hemorrhage- Shock Correct Answer If the patient is hemorrhaging, efforts are made to stop the bleeding. This may involve applying pressure to the bleeding site or surgical interventions to stop internal bleeding. If the cause of the hypovolemia is diarrhea or vomiting, medications to treat diarrhea and vomiting are given while efforts are made to identify and treat the cause. In older adult patients, dehydration may be the cause of hypovolemic shock. Shock Septic- Dopamine Correct Answer Dopamine, a naturally occurring precursor of norepinephrine and epinephrine, functions as a neurotransmitter. Dopamine is useful in hypovolemic and cardiogenic shock. Adequate fluid therapy is necessary for maximal pressor (increased blood pressure) effect. Acidosis decreases the effectiveness of the drug. If fluid therapy alone does not effectively improve tissue perfusion, vasopressor agents, specifically norepinephrine or dopamine, may be initiated to achieve a MAP of 65 mm Hg or higher AAA- Tests Correct Answer The most important diagnostic indication of an abdominal aortic aneurysm is a pulsatile mass in the middle and upper abdomen. Most clinically significant aortic aneurysms are palpable during routine physical examination; however, the sensitivity depends upon the size of the aneurysm, abdominal girth of the patient (i.e., more difficult to find in the patient with obesity), and the skill of the examiner. A systolic bruit may be heard over the mass. Duplex ultrasonography or CTA is used to determine the size, length, and location of the aneurysm. When the aneurysm is small, ultrasonography is conducted at 6- month intervals until the aneurysm reaches a size so that surgery to prevent rupture is of more benefit than the possible

complications of a surgical procedure. Some aneurysms remain stable over many years of monitoring. AAA- Post Op Correct Answer The patient who has had an endovascular repair must lie supine for 6 hours; the head of the bed may be elevated up to 45 degrees after two hours. The patient needs to use a bedpan or urinal while on bed rest. Vital signs and Doppler assessment of peripheral pulses are performed initially every 15 minutes and then at progressively longer intervals if the patient's status remains stable. The access site (usually the femoral artery) is assessed when vital signs and pulses are monitored. The nurse assesses for bleeding, pulsation, swelling, pain, and hematoma formation. Skin changes of the lower extremity, lumbar area, or buttocks that might indicate signs of embolization, such as extremely tender, irregularly shaped, cyanotic areas, as well as any changes in vital signs, pulse quality, bleeding, swelling, pain, or hematoma, are immediately reported to the primary provider. The patient's temperature should be monitored every four hours, and any signs of postimplantation syndrome should be reported. Postimplantation syndrome typically begins within 24 hours of stent-graft placement and consists of a spontaneously occurring fever, leukocytosis, and occasionally, transient thrombocytopenia. This condition has been attributed to complex immunologic changes that occur because of manipulations with sheaths and catheters with the aortic lumen, although the exact etiology is unknown. The symptoms are thought to be related to the activation of cytokines. They can be managed with a mild analgesic (e.g., acetaminophen [Tylenol]) or an anti-inflammatory agent (e.g., ibuprofen [Motrin]) and usually subside within a week. Because of the increased risk of hemorrhage, the primary provider is also notified of persistent coughing, sneezing, vomiting, or systolic blood pressure greater than 180 mm Hg. Most patients can resume their pre-proce

Asystole Drug Choice Correct Answer In such cases, the treatment is the same as for asystole and pulseless electrical activity (PEA) if the patient is in cardiac arrest or for bradycardia if the patient is not in cardiac arrest. Interventions include identifying the underlying cause; administering IV epinephrine, atropine, and vasopressor medications; and initiating emergency transcutaneous pacing. In some cases, idioventricular rhythm may cause no symptoms of reduced cardiac output. Ventricular asystole is treated the same as PEA. Dysthythmias and Calium Correct Answer A low calcium level could lead to severe ventricular dysrhythmias, prolonged QT, and cardiac arrest. Calcium blood levels help maintain normal heartbeats, while low levels can simultaneously cause polarization and depolarization of cardiac cells, and thereby predispose the heart to arrhythmias. ***FROM GOOGLE ETT Assessment Correct Answer The nurse plays a vital role in assessing the patient's status and the functioning of the ventilator. In assessing the patient, the nurse evaluates the patient's physiologic status and how he or she is coping with mechanical ventilation. Physical assessment includes systematic assessment of all body systems, with an in-depth focus on the respiratory system. Respiratory assessment includes vital signs, respiratory rate and pattern, breath sounds, evaluation of spontaneous ventilatory effort, and potential evidence of hypoxia (e.g., skin color). Increased adventitious breath sounds may indicate a need for suctioning. The nurse maintains the patient's head of the bed so that it is elevated 30° or higher unless contraindicated to prevent the risk of aspiration and VAP. The nurse evaluates the settings and functioning of the mechanical ventilator, as described previously, and verifies endotracheal tube position as applicable. Assessment also addresses the patient's neurologic status and effectiveness of coping with the need for assisted ventilation and the changes that accompany it. The nurse assesses the patient's

comfort level and ability to communicate as well. Because weaning from mechanical ventilation requires adequate nutrition, it is important to assess the patient's gastrointestinal system and nutritional status. Thoracotomy- water seal functuality Water Seal System Correct Answer The traditional water seal system (or wet suction) for chest drainage has three chambers: a collection chamber, a water seal chamber, and a wet suction control chamber. The collection chamber acts as a reservoir for fluid draining from the chest tube. It is graduated to permit easy measurement of drainage. Suction may be added to create negative pressure and promote drainage of fluid and removal of air. The suction control chamber regulates the amount of negative pressure applied to the chest. The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction. After the suction is turned on, bubbling appears in the suction chamber. A positive- pressure valve is located at the top of the suction chamber that automatically opens with increases in positive pressure within the system. Air is automatically released through a positive-pressure relief valve if the suction tubing is inadvertently clamped or kinked. The water seal chamber has a one-way valve or water seal that prevents air from moving back into the chest when the patient inhales. There is an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water seal chamber is normal, but continuous bubbling can indicate an air leak. Bubbling and tidaling do not occur when the tube is placed in the mediastinal space; however, fluid may pulsate with the patient's heartbeat. If the chest tube is connected to gravity drainage only, suction is not used. The pressure is equal to the water seal only. Two-chamber chest drainage systems (water

seal chamber and collection chamber) are available for use with patients who need only gravity drainage. The water level in the water seal chamber reflects the negative pres Thoracotomy- water seal functuality Dry Suction Water Seal System Correct Answer Dry suction water seal systems, also referred to as dry suction, have a collection chamber for drainage, a water seal chamber, and a dry suction control regulator. The water seal chamber is filled with water to the 2-cm level. Bubbling in this area can indicate an air leak. The dry suction control regulator provides a dial that conveniently regulates the vacuum to the chest drain. The system does not contain a suction control chamber filled with water. Without a water-filled suction chamber, the machine is quieter. However, if the container is knocked over, the water seal may be lost. Once the tube is connected to the suction source, the regulator dial allows the desired level of suction to be set; the suction is increased until an indicator appears. The indicator has the same function as the bubbling in the traditional water seal system—that is, it indicates that the vacuum is adequate to maintain the desired level of suction. Some drainage systems use a bellows (a chamber that can be expanded or contracted) or an orange- colored float device as an indicator of when the suction control regulator is set. When the water in the water seal rises above the 2-cm level, intrathoracic pressure increases. Dry suction water seal systems have a manual high-negativity vent located on top of the drain. The manual high-negativity vent is pressed until the indicator appears (either a float device or bellows) and the water level in the water seal returns to the desired level, indicating that the intrathoracic pressure is decreased. Chest Tube Deep Breathing Correct Answer Encourage the patient to perform deep breathing, coughing, and incentive

spirometry. Assist with repositioning or ambulation as ordered. Provide adequate analgesia. Breathing techniques, such as diaphragmatic and pursed-lip breathing, taught prior to surgery should be performed by the patient every 2 hours to expand the alveoli and prevent atelectasis. Sustained maximal inspiration therapy or incentive spirometry promotes lung inflation, improves the cough mechanism, and allows early assessment of acute pulmonary changes Subcutaneous Emphysema Correct Answer Subcutaneous emphysema is the medical term for air becoming trapped in tissues beneath the skin. The condition is rare, but it can occur as a result of trauma, injury, infection, or certain medical procedures. Doctors sometimes refer to subcutaneous emphysema as crepitus, tissue emphysema, or subcutaneous air. On physical examination, the most common finding associated with subcutaneous emphysema is crepitus on palpation. Distention or bloating may be present in the abdomen, chest, neck, and face. Palpebral closure resulting in visual distortion and phonation changes from vocal cord compression may also be present. (FROM GOOGLE) Esophageal Cancer- Aspiration Correct Answer Immediate postoperative care is similar to that provided for patients undergoing thoracic surgery. It is not uncommon for patients to have a tracheostomy and be placed in an intensive care unit or step-down unit. After recovering from the effects of anesthesia, the patient is placed in a low Fowler position, and later in a Fowler position, to help prevent reflux of gastric secretions. The patient is observed carefully for regurgitation and dyspnea. A common postoperative complication is aspiration pneumonia. Therefore, the patient is placed on a vigorous pulmonary plan of care that includes incentive spirometry, sitting up in a chair, and, if necessary, nebulizer treatments. Chest physiotherapy is avoided

due to the risk of aspiration. The patient's temperature is monitored to detect any elevation that may indicate aspiration or seepage of fluid through the operative site into the mediastinum, which would indicate an esophageal leak. Drainage from the cervical neck wound, usually saliva, is evidence of an early esophageal leak. Typically, no treatment other than maintaining NPO status and parenteral or enteral support is warranted Ileal conduit- postop complications Correct Answer Complications that may follow placement of an ileal conduit include wound infection or wound dehiscence, urinary leakage, ureteral obstruction, hyperchloremic acidosis, small bowel obstruction, ileus, and gangrene of the stoma. Delayed complications include ureteral obstruction, contraction or narrowing of the stoma (stenosis), kidney deterioration due to chronic reflux, pyelonephritis, renal calculi, and cancer recurrence Burns Electrical Correct Answer Electrical injuries are devastating and complex burns. Heat generated by electricity is directly responsible for tissue damage, but unlike most thermal burns, visual examination is not predictive of burn size and severity. It is helpful to know the circumstances of the injury to anticipate potential tissue damage and complications. Superficial injuries present themselves as contact points on physical examination. Deep tissue injuries may not be visible on initial clinical presentation but in most circumstances should be assumed on presentation so that timely intervention may be initiated. Mechanisms of injury include flash, conductive, and lightning injury.Resuscitation fluid calculations based on total body surface area are inaccurate in conductive electrical injuries, including some lightning injuries. It is difficult to quantify the extent of tissue injury without surgical exploration because the damage may not be visible on physical examination. Serum creatinine kinase levels are useful in determining the degree of muscle injury in the early phases of care. Myoglobinuria, common with muscle damage,

may cause kidney failure if not treated. IV fluid administration titrated to a higher target of urine output per hour than usual may be indicated until the urine is no longer red. It is common practice to add 50 mEq of sodium bicarbonate per liter of IV fluid in an effort to assist in alkalinizing the urine. Serum myoglobin and urine myoglobin levels may be monitored as indicators of the need for continued resuscitation. Finally, the surgical treatment of an electrical injury is as complex as the injury itself. Vasculature is commonly affected; thus, progressive tissue necrosis occurs over time. Sequential surgical débridement may be necessary, using caution to preserve viable tissue. Burns Full Thickness Correct Answer Third-degree (full-thickness) burns involve total destruction of the epidermis, dermis, and, in some cases, damage of underlying tissue. Wound color ranges widely from pale white to red, brown, or charred. The burned area lacks sensation because nerve fibers are damaged. The wound appears leathery and dry due to the destruction of the microcirculation; hair follicles and sweat glands are destroyed. The severity of this burn is often deceiving to patients because they have no pain in the injury area Burns Partial Thickness Correct Answer Second-degree burns involve the entire epidermis and varying portions of the dermis. They are painful and are typically associated with blister formation. Healing time depends on the depth of dermal injury and typically ranges from 2 to 3 weeks. Hair follicles and skin appendages remain intact. HIV Candidiasis Correct Answer Oropharyngeal and esophageal candidiasis (fungal infections) are common in patients with HIV infection. Oropharyngeal candidiasis is characterized by painless, creamy white, plaque-like lesions that can occur on the buccal surface, hard or soft palate, oropharyngeal mucosa, or tongue

surface. Lesions can be easily scraped off with a tongue depressor or other instrument which is in contrast to lesions associated with oral hairy leukoplakia. In women with early-stage HIV infection, Candida vulvovaginitis usually presents the same as in women without HIV infection, with white adherent vaginal discharge associated with mucosal burning and itching of mild-to- moderate severity and sporadic recurrences AIDS Dementia Correct Answer HIV encephalopathy was formerly referred to as AIDS dementia complex (see Chart 36-10). It is a clinical syndrome that is characterized by a progressive decline in cognitive, behavioral, and motor functions as a direct result of HIV infection. HIV has been found in the brain and cerebrospinal fluid (CSF) of patients with HIV encephalopathy. The brain cells infected by HIV are predominantly the CD4+ cells of monocyte-macrophage lineage. HIV infection is thought to trigger the release of toxins or lymphokines that result in cellular dysfunction, inflammation, or interference with neurotransmitter function rather than cellular damage. Chronic confusion Colon Cancer- Tumor Marker Correct Answer Baseline carcinoembryonic antigen (CEA) level is also obtained. CEA is a tumor marker that is recommended for assessing the presence of colorectal cancer, as well as its progression or recurrence, although it does yield both false-positives and false-negatives (NCI, 2016b). However, at present there is no other readily available tumor marker test. Therefore, CEA is not used as the sole predictor of tumor status, including progression or recurrence. Other tests indicated include contrast CT scans of the abdomen, pelvis, and chest, to screen for extent of the tumor and any metastases. Burns Agitation Correct Answer Treatment of anxiety with benzodiazepines may be used along with opioids.

Burns Fluid Replace Correct Answer 2 X kg X Burn % Half first 8 hours, second half last 16 hours To reduce the risk of fluid overload and consequent heart failure and pulmonary edema, daily weights and careful calculation of intake and output measurement are utilized to guide therapy. Changes in physical assessment and hemodynamic indicators are also useful in evaluating the patient's response to treatment. Radiation Therapy- Lung Correct Answer Radiation therapy may offer a cure in a small percentage of patients. It is useful in controlling neoplasms that cannot be surgically resected but are responsive to radiation. Radiation therapy usually is toxic to normal tissue within the radiation field, and this may lead to complications such as esophagitis, pneumonitis, and radiation lung fibrosis, although the incidence of these complications has decreased over time with improvements in delivery of radiation therapy Skin lesions- possible kaposi's sarcoma Correct Answer Kaposi Sarcoma KS is caused by human herpesvirus-8 (HHV-8); affects eight times more men than women; and may spread through sexual contact. It involves the epithelial layer of blood and lymphatic vessels. AIDS-related KS exhibits a variable and aggressive course, ranging from localized cutaneous lesions to disseminated disease involving multiple organ systems. Cutaneous signs may be the first manifestation of HIV; they can appear anywhere on the body and are usually brownish pink to deep purple. They may be flat or raised and surrounded by ecchymosis (hemorrhagic patches) and edema. Rapid development of lesions involving large areas of skin is associated with extensive disfigurement and significant body image issues. The location and size of some lesions can lead to venous stasis, lymphedema, and pain.

Ulcerative lesions disrupt skin integrity and increase discomfort and susceptibility to infection. The most common sites of visceral involvement are the lymph nodes, gastrointestinal tract, and lungs. Involvement of internal organs may eventually lead to organ failure, hemorrhage, infection, and death HIV CD4 count- pathology Correct Answer The CD4+ count serves as the major laboratory indicator of immune function and prophylaxis for opportunistic infections, and is the strongest predictor of subsequent disease progression and survival. An adequate CD4+ response for most patients on ART is an increase in CD4+ count in the range of 50 to 150 mm3 per year, generally with an accelerated response in the first three months. In the United States, ART is now recommended for all HIV-infected patients regardless of their viral load or CD4+ count. Heat Stroke Correct Answer The most serious of these—heat stroke—is an acute medical emergency caused by failure of the heat-regulating mechanisms of the body. It is the inability to maintain cardiac output in the face of moderately high body temperatures and is associated with dehydration. The most common cause of heat stroke is nonexertional, prolonged exposure to an environmental temperature of greater than 39.2°C (102.5°F), although a heat index of greater than 35°C (95°F) is associated with increased mortality. It usually occurs during extended heat waves, especially when they are accompanied by high humidity. Exertional heat stroke is caused by strenuous physical activity that occurs in a hot environment. The nurse provides the following advice for the patient treated for heat-induced illness: Avoid immediate re-exposure to high temperatures; hypersensitivity to high temperatures may remain for a considerable time. Maintain adequate fluid intake, wear loose clothing, and reduce activity in hot weather.

Monitor fluid losses and weight loss during workout activities or exercise and replace fluids and electrolytes. Use a gradual approach to physical conditioning, allowing sufficient time for return to baseline temperature. Plan outdoor activities to avoid the hottest part of the day (between 10 AM and 2 PM). For older patients living in urban settings with high environmental temperatures: The nurse directs these patients to places where air conditioning is available (e.g., shopping mall, library, church) and advises them that fans alone are not adequate to prevent heat-induced illness. Closed head injury- ICP monitoring Correct Answer ICP is monitored closely; if increased, it is managed by maintaining adequate oxygenation, elevating the head of the bed, and maintaining normal blood volume. Devices to monitor ICP or drain CSF can be inserted during surgery or at the bedside using aseptic technique. The patient is cared for in the intensive care unit (ICU), where expert nursing care and medical treatment are readily available. ICP Monitoring Correct Answer The purposes of ICP monitoring are to identify increased pressure early in its course (before cerebral damage occurs), to quantify the degree of elevation, to initiate appropriate treatment, to provide access to CSF for sampling and drainage, and to evaluate the effectiveness of treatment. ICP can be monitored with the use of an intraventricular catheter (ventriculostomy), a subarachnoid bolt, an epidural or subdural catheter, or a fiberoptic transducer-tipped catheter placed in the subdural space or in the ventricle. Increased ICP Treatment Correct Answer Increased ICP is a true emergency and must be treated promptly. Invasive monitoring of ICP is an important component of management. Immediate management to relieve increased ICP requires decreasing

cerebral edema, lowering the volume of CSF, or decreasing cerebral blood volume while maintaining cerebral perfusion. These goals are accomplished by administering osmotic diuretics, restricting fluids, draining CSF, controlling fever, maintaining systemic blood pressure and oxygenation, and reducing cellular metabolic demands Autonomic Dysreflexia- Document Correct Answer Autonomic dysreflexia, also known as autonomic hyperreflexia, is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in people without SCI. It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis above the spinal level of the lesion (most often of the forehead), nausea, nasal congestion, and bradycardia. It occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided. A number of stimuli may trigger this reflex: distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction); or stimulation of the skin (tactile, pain, thermal stimuli, pressure ulcer). Because this is an emergency situation, the objectives are to remove the triggering stimulus and to avoid the possibility of serious complications SCI- intermediate intervention Correct Answer The immediate management at the scene of the injury is critical because improper handling of the patient can cause further damage and loss of neurologic function. Any patient who is involved in a motor vehicle crash, a diving or contact sports injury, a fall, or any direct trauma to the head and neck must be considered to have SCI until such an injury is ruled out. Initial care must include a rapid assessment, immobilization, extrication, and stabilization or control of life-threatening injuries, and transportation to the most appropriate medical facility. Immediate transportation to a trauma

center with the capacity to manage major neurologic trauma is then necessary. At the scene of the injury, the patient must be immobilized on a spinal (back) board, with the head and neck maintained in a neutral position, to prevent an incomplete injury from becoming complete. One member of the team must assume control of the patient's head to prevent flexion, rotation, or extension; this is done by placing the hands on both sides of the patient's head at about ear level to limit movement and maintain alignment while a spinal board and cervical immobilizing device is applied. If possible, at least four people should slide the patient carefully onto a board for transfer to the hospital. Head blocks should also be considered, as they will further limit any neck movement. Any twisting movement may irreversibly damage the spinal cord by causing bony fragment or disc movement or exacerbating ligamentous injury, causing further instability. The patient is referred to a regional spinal injury or trauma center because of the multidisciplinary personnel and support services required to counteract the destructive changes that occur in the first 24 hours after injury. Traumatic Brain Injury- ICP Correct Answer There is ongoing controversy about the use of hyperventilation therapy in traumatic brain injury. This therapy is used in some circumstances to reduce ICP by causing cerebral vasoconstriction and a decrease in cerebral blood volume. The nurse collaborates with the respiratory therapist in monitoring the PaCO2, which is usually maintained at less than 30 mm Hg. Employing hyperventilation should follow guidelines for management of TBI as it involves risk of cerebral vasoconstriction and ischemia. Patients undergoing hyperventilation therapy also benefit from multimodality monitoring to determine the overall effect of this therapy on brain perfusion.

Automatic Dysreflexia S&S Correct Answer This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis above the spinal level of the lesion (most often of the forehead), nausea, nasal congestion, and bradycardia. It occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided. SCI Assess Correct Answer The patient's breathing pattern and the strength of the cough are assessed and the lungs are auscultated, because paralysis of the diaphragm, in addition to abdominal and respiratory muscles, diminishes coughing and makes clearing of bronchial and pharyngeal secretions difficult. Reduced excursion of the chest also results. The patient is monitored closely for any changes in motor or sensory function and for symptoms of progressive neurologic damage. In the early stages of SCI, determining whether the cord has been severed may not be possible, because signs and symptoms of cord edema are indistinguishable from those of cord transection. Edema of the spinal cord may occur with any severe cord injury and may further compromise spinal cord function. Motor and sensory functions are assessed through careful neurologic examination. These findings are recorded on a flow sheet so that changes in the baseline neurologic status can be monitored closely and accurately. The ASIA classification is commonly used to describe the level of function for patients with SCI. The patient is also assessed for spinal shock, which is a complete loss of all reflex, motor, sensory, and autonomic activity below the level of the lesion that causes bladder paralysis and distention. The lower abdomen is palpated for signs of urinary retention and overdistention of the bladder. Further assessment is made for gastric dilation and paralytic ileus caused by an atonic bowel, a result of autonomic disruption.

Temperature is monitored because the patient may have periods of hyperthermia as a result of altered temperature control, which is due to the inability to perspire related to autonomic disruption. DIC Correct Answer Disseminated intravascular coagulation (DIC) is not an actual disease but a sign of an underlying condition. DIC may be triggered by sepsis, trauma, cancer, shock, abruptio placentae, toxins, allergic reactions, and other conditions; the vast majority (two-thirds) of cases of DIC are initiated by an infection or a malignancy. Patients with frank DIC may bleed from mucous membranes, venipuncture sites, and the GI and urinary tracts. The bleeding can range from minimal occult internal bleeding to profuse hemorrhage from all orifices. Patients typically develop MODS, and they may exhibit acute kidney injury as well as pulmonary and multifocal central nervous system infarctions as a result of microthromboses, macrothromboses, or hemorrhages. Clinically, the diagnosis of DIC is often established by laboratory tests that reflect consumption of platelets and clotting factors (i.e., drop in platelet count, an elevation in fibrin degradation products and D-dimer, an increase in PT and aPTT, and a low fibrinogen level) Cardiac Tamponade PEA Correct Answer Pulseless electrical activity (PEA) refers to cardiac arrest in which the electrocardiogram shows a heart rhythm that should produce a pulse, but does not. Pulseless electrical activity is found initially in about 55% of people in cardiac arrest. Common causes of PEA are cardiac tamponade, dynamic lung hyperinflation, tension pneumothorax, and coronary artery graft occlusion or dehiscence. Severe hypovolemia due to blood loss (e.g., into the chest) may also manifest as PEA Pneumothorax Action Correct Answer Pneumothorax may occur after thoracic surgery if there is an air leak from the surgical site to the pleural cavity or from the pleural cavity to the environment.

Failure of the chest drainage system prevents return of negative pressure in the pleural cavity and results in pneumothorax. In the postoperative patient, pneumothorax is often accompanied by hemothorax. The nurse maintains the chest drainage system and monitors the patient for signs and symptoms of pneumothorax: increasing shortness of breath, tachycardia, increased respiratory rate, and increasing respiratory distress Pneumonectomy Chest Tube Correct Answer After a pneumonectomy, the operated side should be dependent so that fluid in the pleural space remains below the level of the bronchial stump and the other lung can fully expand Hepatic Failure- Ascites Correct Answer Increased abdominal girth and rapid weight gain are common presenting symptoms of ascites. The patient may be short of breath and uncomfortable from the enlarged abdomen, and striae and distended veins may be visible over the abdominal wall. Umbilical hernias also occur frequently in those patients with cirrhosis. Fluid and electrolyte imbalances are common. As a result of liver damage, large amounts of albumin-rich fluid, 20 L or more, may accumulate in the peritoneal cavity as ascites. (Ascites may also occur with disorders such as cancer, kidney disease, and heart failure.) With the movement of albumin from the serum to the peritoneal cavity, the osmotic pressure of the serum decreases. This, combined with increased portal pressure, results in movement of fluid into the peritoneal cavity Esophageal Varices Repair Correct Answer Several surgical procedures have been developed to treat esophageal varices and to minimize rebleeding, but these procedures have significant risk. Procedures that may be used for esophageal varices are direct surgical ligation of varices; splenorenal, mesocaval, and portacaval venous shunts to relieve portal pressure; and

esophageal transection with devascularization. The use of these procedures is controversial, and studies regarding their effectiveness and outcomes continue. What is known thus far is that these procedures are very effective in controlling variceal bleeding. They may be considered as second-line management (rescue therapy) in those patients for whom all other treatments have failed, those who are not candidates for liver transplantation, and those who require a bridge to transplantation. There is a high incidence of encephalopathy after the surgical shunting procedures, and morbidity and mortality statistics remain high (Lee & Moreau, 2015). The TIPS procedure has largely replaced the use of surgical decompression shunts and ligation procedures but these interventions may still be used in some cases to manage esophageal varices. Sepsis- Nursing Support During Weaning Correct Answer Nursing Support During Weaning: Soon after the patient is admitted, a consultation with a dietitian or nutrition support team should be arranged to plan the best form of nutritional replacement. Adequate nutrition may decrease the duration of mechanical ventilation and prevent other complications, especially sepsis. Sepsis can occur if bacteria enter the bloodstream and release toxins that, in turn, cause vasodilation and hypotension, fever, tachycardia, increased respiratory rate, and coma. Aggressive treatment of sepsis is essential to reverse this threat to survival and to promote weaning from the ventilator when the patient's condition improves Sepsis- Interventions Correct Answer Nurses caring for patients in any setting must keep in mind the risks of sepsis and the high mortality rate associated with sepsis and septic shock. All invasive procedures must be carried out with aseptic technique after careful hand hygiene. In addition, IV lines, arterial and venous puncture sites, surgical incisions, traumatic wounds, and urinary catheters must be monitored for signs of infection. Nursing

interventions to prevent infection need to be implemented in the care of all patients. Nurses should identify patients who are at particular risk for sepsis and septic shock (i.e., older adults and immunosuppressed patients and those with extensive trauma, burns, or diabetes), keeping in mind that these high-risk patients may not develop typical or classic signs of infection and sepsis. However, confusion with or without agitation along with an increased respiratory rate may be the first sign of infection and sepsis in any adult patient When caring for a patient with sepsis or septic shock, the nurse collaborates with other members of the health care team to identify the site and source of sepsis and the specific organisms involved. The nurse often obtains appropriate specimens for culture and sensitivity. Prescribed antibiotics are not given until these specimens are obtained. Hyperthermia (elevated body temperature) is common with sepsis and raises the patient's metabolic rate and oxygen consumption. Efforts may be made to reduce the temperature by administering acetaminophen or applying a hypothermia blanket. During these therapies, the nurse monitors the patient closely for shivering, which increases oxygen consumption. Efforts to increase comfort are important if the patient experiences fever, chills, or shivering. The nurse administers prescribed IV fluids and medications, including antibiotic agents and vas MODs Correct Answer In MODS, the sequence of organ dysfunction varies depending on the patient's primary illness and comorbidities before experiencing shock. Advanced age, malnutrition, and coexisting disease appear to increase the risk of MODS in acutely ill patients. For simplicity of presentation, the classic pattern is described. Typically, the lungs are the first organs to show signs of dysfunction. The patient experiences progressive dyspnea and respiratory failure that are manifested as ALI or ARDS, requiring intubation and mechanical ventilation. The patient usually remains hemodynamically stable but may

require increasing amounts of IV fluids and vasoactive agents to support BP and cardiac output. Signs of a hypermetabolic state, characterized by hyperglycemia (elevated blood glucose level), hyperlactic acidemia (excess lactic acid in the blood), and increased BUN, are present. The metabolic rate may be 1.5 to 2 times the basal metabolic rate. At this time, there is a severe loss of skeletal muscle mass (autocatabolism) to meet the high energy demands of the body. After approximately 7 to 10 days, signs of hepatic dysfunction (e.g., elevated bilirubin and liver function tests) and renal dysfunction (e.g., elevated creatinine and anuria) are evident. As the lack of tissue perfusion continues, the hematologic system becomes dysfunctional, with worsening immunocompromise, increasing the risk of bleeding. The cardiovascular system becomes unstable and unresponsive to vasoactive agents, and the patient's neurologic response progresses to a state of unresponsiveness or coma. The goal of all shock states is to reverse the tissue hypoperfusion and hypoxia. Shock Symptoms Correct Answer The sequence of events in hypovolemic shock begins with a decrease in the intravascular volume. This results in decreased venous return of blood to the heart and subsequent decreased ventricular filling. Decreased ventricular filling results in decreased stroke volume (amount of blood ejected from the heart) and decreased cardiac output. When cardiac output drops, BP drops and tissues cannot be adequately perfused. Dissecting Abdominal Aneurysm Correct Answer An aortic dissection is a serious condition in which a tear occurs in the inner layer of the body's main artery (aorta). Blood rushes through the tear, causing the inner and middle layers of the aorta to split (dissect). An aortic aneurysm occurs when a weak spot in the wall of the aorta begins to bulge, as shown in the image on the left. An

aneurysm can occur anywhere in the aorta. Having an aortic aneurysm increases the risk of a tear in the aortic lining (aortic dissection). An abdominal aortic aneurysm is an enlarged area in the lower part of the major vessel that supplies blood to the body (aorta). The aorta runs from the heart through the center of the chest and abdomen. The aorta is the largest blood vessel in the body, so a ruptured abdominal aortic aneurysm can cause life- threatening bleeding. ***FROM GOOGLE Near Drowning Correct Answer Nonfatal drowning is defined as survival for at least 24 hours after submersion that caused a respiratory arrest. The most common consequence is hypoxemia. The nonfatal drowning process involves the onset of hypoxia, hypercapnia, bradycardia, and arrhythmias. If there is a violent struggle associated with the nonfatal drowning episode, exercise- induced acidosis and tachypnea can result in aspiration. Hypoxia and acidosis cause eventual apnea and loss of consciousness. When the victim loses consciousness and makes a final effort to breathe, the terminal gasp occurs. Water then moves passively into the airways prior to death. After resuscitation, hypoxia and acidosis are the major complications experienced by a person who has experienced nonfatal drowning; immediate intervention in the ED is essential. Bite Priority Correct Answer Initial first aid at the site of the snakebite includes having the person lie down, removing constrictive items such as rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. CABs are the priorities of care. Ice, incision and suction, or a tourniquet is not applied. Tetanus and analgesia should be given as necessary. Initial evaluation in the ED is performed quickly and includes information about the following