MDC 4: FINAL EXAM Terms in this set (125) The "E" in the primary survey stands for Exhale. TRUE/FALSE FALSE "E" stands for exposure Primary survey (ABCDE) A: airway/cervical spine B: breathing C: circulation D: disposition (checking neuro

MDC 4: FINAL EXAM Terms in this set (125) The "E" in the primary survey stands for Exhale. TRUE/FALSE FALSE "E" stands for exposure Primary survey (ABCDE) A: airway/cervical spine B: breathing C: circulation D: disposition (checking neuro status/GCS) E: exposure Assessments findings for airway and cervical spine.... -airway open -jaw thrust monuver -head tilt When used jaw thrust monuver instead of tilting the head.... neck injury--any kind of cervical neck injury Client has asymmetrical chest movement and complaining SOB. You suppect a pneumothroax, what is the intervention.... chest tube Treatment for frostbite include all except: A. Warm bath B. IV hydration C. administer tetanus vaccine D. warm with friction D. warm with friction--that can cause more damage to the tissue 4 stages of Frostbite 1. redness 2. fluid-filled, milky blisters 3. bloody blisters 4. tissue necrosis Frostbite -can occur when the skin is not properly protected from extremes in cold temp. -frostbite has degrees, much like burns, with fourth-degree being the deepest -at stage four, gangrene may develop, and amputation may be necessary Frostbite Tx -warm bath -IV hydration -administer tetanus vaccine -warm gauze or dressings loosly -stop the exposure to cold -if the client has frostnip don't rub the skin to rewarm -for frostbite the client is submerged in a warm tub for rewarming -the rewarming process in painful -administer analgesics -watch for the development of compartment syndrome from the swelling -severe frostbite is managed much like a thermal burn Clinical manifestations of Heat Stroke include: A. hot skin, oliguria, ALOC B. paradoxical chest movement C. red skin with blisters D. shivering A. hot skin, oliguria, ALOC -temp. goes up to 104 degrees If a patient has heat stroke and ALOC do you want to feed them? NO! aspiration risk If heat exhaustion is not treated, it can progress to.... progress to heat stroke Heat stroke is a true medical emergency associated with a high mortality rate Heat Stroke interventions -is an medical emergency -start with fluids -watch dysthrimas, tachycardia -put ice/cold packs on groin, abdomen, under arms, neck -cool fluids -don't feed the patient -bring to shady area -put water on body -call 911 -if they shiver give BENZOS -IV sline in hospital -electrolyte labs -expect high H/H r/t hemoconcentration -O2 -REMEMBER! they are at risk for hypovolemic shock Heat stroke causes & Sx -body temp. rises to about 104F -Exertional heat stroke --a person wearing too many clothes while doing strenuous physical activity -classic heat stroke --exposure to heat & humidity -skin may be dry or perspiring -mental status change due to heat injury to the brain -HpoTN, tachycardia, & tachypnea -seizures---coma Red skin with blisters.... -describing burns 2nd degree -describing frostbite 2nd degree Do we want shivering with a client who has a heat stroke.... -NO, because it creates heat -give BENZOS to decrease temp. Assessing clients to determine severity of illness/injury before administering care is: A. disaster response B. external disaster C. black tagging D. triage D. triage Clients that would need to be seen first as an emergent (life-threatening) in triage.... -chest pain -bleeding out -ABCs -SOB -strokes -ALOC -allergic rxn -respiratory distress -unstable VS Clients that would need to be seen urgent in triage.... -uncomplicated/displaces fractures -cough with a temp. -burns low degree -severe abdominal pain (bleed, pandicites) -renal colic (clients who are passing kidney stones) -food poisioning -pneumonia in older adults Client that would be seen in non-urgent in triage.... -stuff nose -earache -cough without temp. -closed fractures -sprains -small cuts -skin rashes -strains -colds EX's of external disasters OUTSIDE the hospital -floods -hurricane -tornados -explosion -fire -train derail -winter storm -terrorist attacks -earthquake EX's of internal disasters INSIDE HOSPITAL -fire in patient trash can -loss of utilities -violence Who gets evacuated first during a fire? ambulatory patients _____is a continued decrease in core body temp. after the victim is removed from the cold environment A. lactic acidosis B. hypokalemia C. after-drop D. flaccid paralysis C. after-drop Ways to warm people up with hypothermia -warm blankets -warm fluids -warm gastric lavage -remove wet clothing -dry them All of the following will be done during the primary survey, except: A. monitor breathing B. splint fractures C. assess for a patent airway D. use tourniquet to stop profuse bleeding B. splint fractures Primary survey -monitor breathing -assess for a patent airway -use tourniquet to stop profues bleeding Secondary survey -splitting fractures -putting fooleys in -inserted NG tubes -going to diagnosting testing -going to the OR -completing an assessment of head to toe Drowning can cause alveolar collapse and ARDS TRUE/FALSE TRUE Causes of ARDS -sepsis -near drowning -trauma -pancreatitis -burns -aspiration pneumonia -getting to much blood -pulmonary contusion -pulmonary embolism -infection ARDS clinical manifestations -refractory hypoxemia -non-cardiac pulmonary edema -crackles -X-ray shows ground glass appearance ARDS Tx -PEEP -prone -mechanically ventilated A sternal rub is the best way to test peripheral response to pain TRUE/FALSE FALSE nail pressure is to test peripheral response to pain Which of the following is an examples of an internal disaster: A. fire in a client's hospital room B. flood C. explosion at a nearby factory D. witner storm A. fire in a client's hospital room In a mass casualty event which client would get a red tag? A. closed fracture of the left tibia B. facial injuries and difficulty breathing C. asystole with a head injury D. dislocated shoulder B. facial injuries and difficulty breathing In traditional triage-which clients would be seen first? A. urgent B. non-urgent C. emergent D. black tags C. emergent -ABCs, shock, MI, stroke The priority medication to give to a client with anaphylaxis is: A. steroids B. epinephrine C. acetaminophen D. aripiprazole B. epinephrine give IM or subq Allergic to contrast die, what other things could be allergic to.... shell fish Allergic to banana, strawberry, kiwi, avocado you are allergic to.... LATEX Allergic to eggs you can be allergic to.... depervan flu vaccine What other medications are we going to give if my client is having anaphylaxis.... -diphenhydramine (bendrly) -also can give steroids, albuterol & antihistamines ok too What type of client's may benefit from be placed in PPIs -burns--to prevent curling ulcers -vented--to prevent VAP -anyone with stress ulcers Your patient had a spinal cord injury and now complaning of a throbbing sudden HA what do you spect and what do you do.... -autonomic dysreflexia -sit them up first -find the cause A group that can help communities during a disaster by setting up first-aid stations: A. HAZMAT B. disaster medical assistance team (DMAT) C. EMTALA D. medical reserve corps D. medical reserve corps Medical Reserve Corps -this is a team make up of medical personal that volunteer and offer their services as support in a supplemental capacity -the team is able to assist in many capacities -the team may set up outside of the hospital an acute care center to take care of patients that are considered noncritical DMAT -supplies for 72 hrs -federal employees RN licenses are good in all the states -this is a medical relief team made up of civilian medical, paraprofessional, & support personnel that is deployed to a disaster area EMTALA -emergency medical treatment and labor act -prohibited ED to send people to other fucilities just b/c they can't afford to pay. HAZMAT -hazardous material team which will come in a case of a spilled. -decontamination Actions to prevent PTSD include all except: A. drink plenty of water B. do not work more than 12 hrs shifts C. get plenty of rest D. drink 2 glasses of wine each night D. drink 2 glasses of wine each night Prevent PTSD.... -drink plenty of water -do not work more than 12 hrs shifts -get plenty of rest -avoid ETOH -avoid caffeine -nutritious meal -talk about your feelings if feeling overwhelmed -stay contact with love one and friends The R in RACE stands for: A. return B. ring the alarm C. rescue D. rest C. rescue Order for fire extinguishers PASS Critical stress debriefing is confidential and non-judgemental TRUE/FALSE TRUE these are the 2 rules of critical debriefing Critical stress debriefing -those involved are at risk for developing acute stress disorder (ASD) or PTSD -staff may find it difficult to "get back to normal" MDC 4: FINAL EXAM Which choice is the best Tx for heat exhaustion A. have the patient lie down in the bleachers B. move patient to a shady area and wet his clothes with water C. offer an umbrella or a hat for shade D. give him a cold soda to drink B. move patient to a shady area and wet his clothes with water When assessing a patient in the ER, what is the priority? A. hemorrhage B. mobility C. breathing D. ecchymosis C. breathing What is the quickest way to cool body temp.? A. provide iced drinks B. appy wet washcloth to forehead C. sponge baths D. remove clothing and linen D. remove clothing and linen Which of the following Sx would be expected in a patient with a pneumothorax? A. bradycardia B. normal O2 saturation C. diminished breath sounds D. sucking sound at the injury site C.diminished breath sounds What is an appropriate action to take if a ventilator malfunctions? A. ventilate the patient manually B. start CPR C. administer O2 per Trach cannula D. check VS A. ventilate the patient manually What is the early sign of ARDS? A. wheezes B. crackles C. cyanosis D. increased RR D. increased RR How do you assess motor function in an unconscious client? A. nail bed pressure B. iced saline to the inner ear C. sternal rub D. pinching the patient in the inner thigh A. nail bed pressure Which intervention can minimize the risk of autonomic dysreflexia? A. provide tight clothing for support B. adhering to a strict bowel retraining program C. limit straight cathing to bid D. placing an adult depends on an incontinet patient B. adhering to a strict bowel retraining program Interventions for a patient with homonymous hemianopsia include all of the following except A. discourage patient from using eye glasses to correct the problem B. approach the client from the impaired side C. move objects to the patients field of vision D. remind client to turn their head to scan the room B. approach the client from the impaired side One risk of Guillian Barre syndrome that can cause an exacerbation is A. recent respiratory infection B. high caffeine intake C. traveling on an airplane D. daily walks of greater then 20 minutes A. recent respiratory infection Which of the following is a sign of meningitis? A. GCS score of 15 B. positive Brudzinski sign C. negative Kernig sign D. absence of nuchal rigidity D. positive Brudzinski sign How is a nurses licenses affected if they are on a DMAT team? A. RN must get a liceneses in every state they wish to work in B. DMAT does not require a nursing license C. DMAT is a federal position, the license is good in all 50 states D. I have no idea what DMAT is, better look it up C. DMAT is a federal position, the license is good in all 50 states Which type of surgical drain works with gravity A. penrose drain B. hemovac C. JP drain D. wound vac A. penrose drain What are the signs of decorticate posturing? A. back hunched over and rigid flexion of all four extremities B. supination of arms and dorsiflexion of the feet C. back arched and rigid extension of all four extremities D. internal rotation and adduction of arms/flexion elbows, wrists, fingers Internal rotation and adduction of arms/flexion elbows, wrists, fingers Cherry red lips are a sign of A. carbon monoxide poisoning B. MI C. CVA D. COPD A. carbon monoxide poisoning Extensive tissue damage after a burn can result in? A. hypercalcemia B. hypernatremia C. hyperkalemia D. hypokalemia C. hyperkalemia Which type of shock can occur after an MI: A. hypovolemic B. cardiogenic C. septic D. neurogenic B. cardiogenic An order states infuse NS 1000 mL over 6 hrs with a gtt factor of 10. What is the rate? A. 32 mL/hr B. 32 gtt/min C. 28 gtt/min D. 28 mL/hr C. 28 gtt/min The parkland formula is TBSA of burn X wt in KG/4 TRUE/FALSE FALSE Assessment findings/interventions that relate to "A" for airway (primary survey) -make sure it's open/patent -jaw-thrust maneuver -intubation -cervical spine -stabilization -artificial airway Assessment findings/interventions that relate to "B" for breathing (primary survey) -lung sounds -chest tube -tracheal deviation (tension pneumothorax) -asymmetrical chest movement (pneumothorax) -paradoxical chest movement (flail chest) MDC 4: FINAL EXAM Assessment findings/interventions that relate to "C" for circulation (primary survey) -IV fluids -vasoconstrictors (norepi, dopamine) -blood products -assess BP, cap refill, pulses Assessment findings/interventions that relate to "E" for Exposure (primary survey) -temperature--hypothermia/hyperthermia -remove clothing Assessment findings/interventions that relate to "D" for disability (primary survey) -neurological status are they wake -respond to voice -respond to pain -GCS (8 indicates coma) Tx for Carbon Monoxide poisoning -high flow O2 -hyperbaric chamber Forensic Nx Examiners (RN-FNEs) -knowledgeable on the correct procedures to collect evidence for victims of rape, child abuse, and domestic violence cases. -the forensic Nx is trained how to correclty document evidence -this specialized Nx also assists the client to develop a safety plan & involves outside agencies to accomplish this goal Psychiatric Crisis Nx Team -the crisis team is called upon to evaluate and assist in determining the disposition of a client that is suicidal. -the team may assist with admission to local psychiatric hospitals -this team also offers support & education to the ER staff in managing cases. -the goal is to assist in developing a discharge plan of care & follow-up Emergency Medical Technicians (EMT) -EMS responders -they can provide basic life support -their duties may vary from state-to-state Paramedics -offer advanced life support (ALS) -pre-hospital team (first responder) initially assess and evaluates the patient -the assessment is communicated to the ER so that preparation for the client's arrival & activation of the appropriate teams takes place before their arrival -paramedics are a valuable part of the ER team Staff safety.... -use std. precautions at all times -follow transmission precautions i.e. airborne -ensure security guards are present -triage area is vulnerable & should have bulletproof glass between staff & visitors -put metal detectors in place -panic buttons are strategically located in rooms