Rasmussen College : NUR 2755/ MDC4 FINAL EXAM
Multidimensional Care IV_LATEST 2021
MDC4 FINAL EXAM
what are the treatments for frostbite in the
... [Show More] 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; >20
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 [Show Less]