NUR2755 / NUR 2755 FINAL EXAM (Latest 2021 / 2022): Multidimensional Care IV / MDC 4 - Ras, Exams of Nursing

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NUR2755 / NUR 2755 FINAL EXAM (Latest

2021 / 2022): Multidimensional Care IV /

MDC 4 - Rasmussen

NUR 2755 Multidimensional Care IV

MDC4 FINAL EXAM

what are the treatments for frostbite in the ED?

• Warm saline, immerse hands/feet in warm water, elevate affected limbs, have them rub their hands together

Priority treatment for pt with a heat stroke

• Move them out of the sun, into shade

First priority assessment

• Airway

Process called for sorting patients

• Triage

Pt with a heat stroke starts to shiver. Why is this this bad?

• Raises their temp.; give them meds

Pt has an increased temp., what will we tell the UAP to do?

• Strip them down/remove clothing

2nd degree frost bite looks like?

• Milky fluid, red w/ blisters

Pt w/ heat stroke--what characteristics would we see in the pt?

• Tachycardia, irregular pulse patter, visual disturbance, dec. urine output

Pt being treated for hypothermia & is on a heart monitor. What is the reason that the pt could have arrhythmias?

• Lactic acid shunted

Pt sustained a blunt trauma to the chest, sign that the pt has a pneumothorax?

• Diminished breath sounds

Low pressure alarms on the ventilator, what do we think happened/what do we do?

• It disconnected; ventilate the pt manually

Pt w/ rib fracture, how would they present?

• Pain on inspiration

Most distinctive sign of flailed chest?

• Paradoxical chest movement

Pt has a high-pressure alarm on the ventilator & absence of breath sounds on the right lower lobe. what do they have?

• Pneumothorax

Earliest signs of respiratory distress?

• Increased resp rate; >

Most common symptoms of a pt w/ a PE?

• Sudden chest pain

Assessing pain for pt who is unconscious, what's the first intervention?

• Nail bed pressure

Pt with a head injury & are arousable, what is one intervention the pt can do themselves to reduce ICP?

• Exhaling during repositioning

Characteristics of CSF, what does it test for?

• Clear w/ a yellow halo; tests positive for glucose

How can we limit autonomic dysreflexia?

• Routine bowel & bladder program

Evaluating a pt for a spinal cord injury; which of the following would indicate shock?

• Flaccid paralysis

Can restraints be used if a pt had a seizure?

• No

Pt with hemianopia, what do we recommend to help overcome their deficit?

• Scanning back & forth

Best thing to teach pt w/ Myasthenia gravis, regarding their medications

• Continue taking meds to maintain blood level

Pt w/ Parkinson's w/ bradykinesia--what to teach them for getting out of a chair?

• Rock back & forth

Pt that has Guillain Barre syndrome--what do we want to know about them?

• If they have a hx/exposure of epstein-barr virus

Pt w/ Guillain Barre & have been intubated; what is the plan of care for the pt to cope w/ this illness?

• Provide info, give positive feedback, & encouraged relaxation

What is the neurological sign for meningitis?

• Brudzinski sign

Pt instructions do we give a pt w/ a halo device?

• Drink w/ a straw, inform pt the device will change their equilibrium/balance, wash under the wool skin

Triage the following:

• Infant w/ petecchiae/104 temp, pt w/ minor head wound, pt w/ abd pain, & pt w/ ankle injury

Giving food to a pt with hemiparesis and has hemiplegia?

• Offer food on the unaffected side

What is the long-term reaction to Dilantin/phenytoin use?

• Gum hyperplasia

Pt that is on Dilantin long-term, what might happen if they abruptly d/c?

• Status epilepticus would develop

Pt is in the postictal phase of a tonic-clonic seizure, what will they look like?

• Tired & drowsy

Priority assessment in pt in the postictal phase?

• Airway

Give instructions/education to a pt going to receive and EEG, can they have anything with caffeine?

• NO caffeine

What would we observe in a pt in the ictal phase?

• Loss of awareness, rigidity; stiffness, violent muscle contractions

Decerebrate posturing?

• The back is arched & all 4 extremities are rigidly extended

What is the desired PTT for heparin therapy?

• 60

Pt with a PTT of 25 seconds, what would we do?

• Increase heparin

Pt is genetically predisposed to a PE; what would we expect to do?

• Teaching for an IVC filter

Pt has a massive blood loss from trauma, what will you expect to see in their MAP?

• It will drop

Pt's RR was 12 and is now at 16, HR 80 and now 92, what is the priority action?

• Continue to monitor/document findings

Pt's WBC: 3.8, BS: 198, Temp: 96.2, what is the priority action?

• Call MD about the temperature.

One thing to give instructions on for older adults in a community to prevent dehydration

• Inc. fluid intake/drink more water

Number 1 lab to look at when evaluating shock

• Lactic acid

Ways to prevent PTSD

• Well balanced meal, drink fluids, take a break when need to, don't work >12 hrs a day, debrief

During a mass casualty, a pt with multiple rib fractures & SOB would get one color tag?

• Red

You are a charge nurse in the ED & getting staff calls and bickering after a week of numerous traumas, what is the first action?

• Debriefing

Pt is found unresponsive in their home & their skin is bright cherry red. What do you suspect happened? What lab to get?

• Carbon monoxide poisoning; carboxyhemoglobin