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NUR 265 TEST 3 – 273 QUESTIONS AND ANSWERS (Galen College of Nursing – Cincinnati)
NUR 265 TEST 3 – 273 QUESTIONS AND ANSWERS (Galen College of Nursing – Cincinnati)
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NUR 265 TEST 3 – 273 QUESTIONSAND ANSWERS (Galen College of
Nursing – Cincinnati)
What causes Autonomic Dysreflexia - -Stimulation at level of T6 or above
-What are some examples of triggers of autonomic dysreflexia - -restrictive
clothing; full bladder/neurogenic bladder; fecal impaction; directive pressure
s/a sitting in the wheel chair
-signs and systems of Autonomic Dysreflexia - -hypertension, flushed face,
headaches, JVD, bradycardic, diaphoresis, pale ext below the level of T6,
nausea, dilated pupils, blurred vision, restlessness
-What is the purpose of fluid resuscitation for a burn victim - -maintain vital
organ perfusion, reduce edema, minimize effects of fluid shifts, prevent
hypovolemic shock
-What IV solution is commonly used to resuscitate a pt with a burn - -
Lactated ringers
-Chemical burns should be irrigated until - -20 minutes or the burn
sensation continues after the 20 minute marker
-what would you use to remove hot tar or asphalt - -citrus petroleum jelly
ex; medisol
petroleum jelly
antibiotic ointment
-what kind of brain injury would you expect if an adult client is positive for
Palmer's infant reflexes - -cortical and premotor cortex damage
-what kind of brain injury would you expect if an adult client is positive for
plantar infant reflexes - -upper motor neuron lesion
-what kind of brain injury would you expect if an adult client is positive for
rooting infant reflex - -frontal lobe damage
-what kind of brain injury would you expect if an adult client is positive for
sucking infant reflex - -Advance dementia; cortical brain damage
-what kind of brain injury would you expect if an adult client is positive for
glabella (persistent blinking) infant reflex - -diffuse cortical dysfunction
,-What is the consensus formula for burns - -2-4 ml X TBSA X KG
-What S&S are expected for a burn client who is receiving the first 8 hours of
fluid resuscitation - -Restlessness, anxiety, Hypothermia
-how much fluid replacement are you going to give the first 8 hours - -1/2 of
the fluid consensus
-What do you need to monitor when resuscitating fluids for burn pt to make
sure that it is working - -Urine output
-Besides a hyperbaric chamber how would you admin o2 to a client with CO
poisoning - -100% O2 with a non-rebreather
-How would you treat a circumferential trunk burn that is swelling and why?
- -Eschartomies R/T constriction of the chest wall expansion
-what are the classification of shock - -Cardiogenic; hypovolemic,
neurogenic, and Disruptive
-All shock is caused by - -inadequate tissue perfusion
-Patho of hypovolemic shock - -Inadequate circulating blood volume S/A
burns, hemorrhage, dehydration
-Patho for cardiogenic shock - -Inadequate pumping action of the heart S/A
MI, CHF, PE
-What are the 3 subclasses of Distributive shock - -Anaphylactic; Septic;
Neurogenic
-Patho for neurogenic shock - -interference of the nervous system that
controls the blood vessels
-Patho for septic shock - -Release of vasoactive substance from the immune
system
-How much blood loss is required for the patient to be at high risk for
hypovolemic shock - -15-25%, or 1/3 of the body blood, or 5L
-clients who experience slow blood loss can - -Tolerate the blood loss better
then a client with rapid blood loss
-Signs and symptoms of compensatory shock - -hypotension, tachycardia,
tachypnea, hypothermia, decrease pulse pressure
, -During compensatory stage of shock, why would you hear hypoactive bowl
sounds and cool and clammy skin - -Body shunting blood from skin, kidneys
and GI to provide adequate blood volume to the brain and heart
-Why would urine output decrease during compensatory stage of shock - -
High production of aldosterone
-why do RR increase in compensatory stage of shock - -The body is going
into acidotic state trying to blow it off Kussmals
-What is the byproduct of anaerobic metabolism that is developing in what
stage of shock - -Lactic acid, Compensatory
-Why would you not give someone with impaired hepatic function lactated
ringers - -Because it does not convert lactic acid into bicarb fast enough
could go into acidosis
-why would you check for high levels of sodium nd glucose in the
compensatory stage of shock - -Because of the release of alderstone and
catecholamines which is used to regulate blood volume
-What stage of shock that lactic acid is at the highest - -progressive
-What happends to the body when build up of lactic acid occurs - -increase
capillary permeability; relaxation of capillary spincter; blood is retaining in
the cap beds
-S&S of the progressive stage of shock - -Hypoxia, alveolar collapse,
pulmonary edema, cardiac dysrhythmias, ischemic heart, ARF, DIC, Mental
status change
-Patho of the progressive stage of shock - -organ suffering from hypoxia,
vasoconstriction decrease cell perfusion, GFR cannot be maintained
-How do you calculate MAP - -Systolic (2 X diastolic) / 3
-Manis of shock - -decrease LOC, Confusion, pale mottled cool skin, poor
skin turgor, cyanosis(late) Delay cap refill, decrease UO, CO, and BP, rapid
and threadie pulse, increase RR, dyspnea, diaphoresis, hypothermia
-Septic shock can lead to - -SIRS
-S&S of Hypovolemic shock - -decrease urine osmolality, and SG (R/T NA
and H2O retention), increase SNS response (S/A rapid RR increase pulse
rate.) Decrease tissue perfusion, Pale appearance, diaphoretic, cyanosis(late)
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