NSG 4100/ NSG4100 Exam 4 (Final Exam)– Latest 2026/2027 Update – Advanced Medical-Surgical Nursing | Questions and Verified Answers | 100 out of 100

NSG 4100/ NSG 4100 Exam 4 (Final Exam)– Latest 2026/2027 Update – Advanced Medical-Surgical Nursing | Questions and Verified Answers | 100 out of 100 2026 / 2027 Academic Year Q: Sign of worsening condition? Answer Pupil size from 5-9 (Know GCS) Q: What is the best position for patient at risk for increased ICP? Answer Semi fowlers Q: When caring for a patient with encephalitis? Answer Keep room dim Answer Set up bedside humidification Q: Patient had Huntington's for 15 years and admitted with pneumonia, what is the priority action? Q: Patient has been ordered pyridostigmine for myasthenia gravis, this med is used for? Answer Improves muscle strength Q: Patient is experiencing myasthenic exacerbation related to a missed dose of meds, what is a sign of this crisis state? Answer Extreme muscle weakness, difficulty speaking, shallow and slow respirations and dysphagia Q: Patient diagnosed with fibromyalgia, a key feature is? Answer Difficulty sleeping » Heat can relieve pain but it will cause triggers Q: What education statement is correct regarding MS and activity and mobility? Answer Walking improves gait Q: Patient sustained C4 injury, expect all of the following symptoms except? Answer Full range of motion Q: Autonomic dysreflexia ais considered an emergency, why? Answer Increase in BP can raise ICP Q: The patient with fibromyalgia is suffering from pain at 12 of the 18 identification sites, including the neck and upper back and the knees. The patient also reports non refreshing sleep, depression and being anxious when dealing with multiple tasks. The nurse should teach the patient about what treatments? Answer Relaxation strategy (biofeedback), serotonin reuptake inhibitor (sertraline), establish a regular sleep pattern. -Patients should be instructed in regular, low impact exercise such as walking, swimming, biking and water exercise -ANTI-DEPRESSANTS such as preglabalin and duloxetine are approved for fibromyalgia nerve pain. These meds work to release SEROTONIN and norepinephrine, neurotransmitters in the brain. Q: The nurse caring for a client with head injury would recognize which assessment findings as early signs of increased ICP? Answer Kussmauls breathing and weakness in one extremity Q: A nurse is caring for a client diagnosed with a head injury, which of the following situations needs intervention by the nurse? Answer The clients spouse turns on the TV one hour in the afternoon and 3 hours in the evening -In a client with head injury, ICP increases. External stimuli should be reduced to decrease oxygen consumption to prevent seizures Q: The critical care nurse is caring for a client with a head injury secondary to a Answer -An epidural hematoma results from bleeding between the dura and the inner surface of the motorcycle accident who, on morning rounds, is responsive to painful stimuli ar assumes decorticate posturing. Two hours later, which data would warrant immediate intervention by the nurse? Answer The client extends the upper and lower extremities in response to painful stimuli. -Extension of the upper and lower extremities is assuming a decerebrate posture, which indicates the clients ICP is increasing Q: The nurse is caring for a client in the ED, which client should the nurse asses first? The client with a epidural hematoma skull, and is an active arterial bleed. This is a medical emergency Q: A female patient has experienced an episode of myasthenic crisis. The nurse would asses whether the patient has precipitating factors such as? Answer Omitting does of medication -Myasthenic crisis often is caused by under medication and responds immediately to cholinergic medications such as neostigmine and pyridostigmine Q: Atropine sulfate Answer neurogenic shock Q: Mannitol Answer increased ICP Q: Mannitol Answer increased ICP Q: Methylprednisone Answer SCI Q: Plasmapheresis Answer Guillain-Barre Q: Hydralazine IV Answer autonomic dysreflexia Q: How long is hospice? Answer Monitor for dysrhythmias Answer 6 months -If the family calls 911 when they are at home on hospice with Cheyne stokes and goes to the ER they are no longer on hospice and will receive full treatment and have to apply again Q: Patient is dx with hypovolemic shock what is the priority action? Q: Patient has severe burns up to 40-50 % of total body surface, HR is increasing, BP is dropping, RR is shallow, what type of shock is this? Answer Hypovolemic Q: A 25 year old female patient has sustained burns to the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned? Answer 37% -Back of right arm (4.5%), posterior trunk (18%), front of left leg (9%), anterior head and neck (4.5%) and perineum (1%) which equals 37%. Q: A 68 year old male patient has partial thickness burns to the front and back of the right and left leg, front of right arm, and anterior trunk. Using the Rule of Nines, calculate the total body surface area percentage that is burned? Answer 58.5% -Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%. Q: A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? Answer Place on cardiac monitor. -After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. Q: A 25-year-old man weighing 70 kg with a 30% TBSA burn was admitted at 4 pm. His burn occurred at 3 pm. He received 1000mL in the field. What is total fluid replacement in 24 hours? How much in first 8 hours and the following 16 hours? Calculate hourly infusion rate in first 8 hours. Answer Total fluid requirement for first 24 hours: 4 ml×(30% total burn surface area)×(70 kg) =8400 ml in 24 hours -Half to be given in first 8 hours, half over the next 16 hours: Will receive 4200 ml during 0 8 hours and 4200 ml during 8-24 hours -Calculate hourly for the first 8 hours: Burn occurred at 3 pm and 1000 given in field, so 8 hour point is 11 pm. It is now 4 pm, so need 3200 ml over next 7 hours: 3200/7 = 457 ml/hour from 4 pm to 11 pm Q: During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? Answer Measure hourly urine output. When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour Q: The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function? Answer Continue to monitor the urine output. -The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. Q: A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? Answer Notify the health care provider and prepare for endotracheal intubation. -The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Q: While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? Answer Wear gowns, caps, masks, and gloves during all care of the patient. -Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation Q: You are assessing a patient using the GCS and her eyes open to pain, she is confused and obeys commands what is her score? Answer 12 Q: Which is an incorrect statement about a patient with a closed head injury s/p MVA? effects of injury peak about 12 to 24 hours Answer -Correct: loss of consciousness associated with stupor and confusion, deep contusions are more often associated with hemorrhage and destruction, & patients are more often managed medically with the goal of preventing more insults What is the best action for obtaining an informed consent for emergency craniotomy for a patient brought by EMS? A woman with suspected epidural hematoma, who may have blacked out at home & answers questions appropriately, what would be the priority nursing action? Answer close monitoring An elderly man with a TBI fell off a ladder yesterday what indicates a worsening condition? Answer swelling optic nerve Answer transport the victim to the operating room for surgery Your patient is due for an aneurysm surgery this morning what situation would require immediate physician notification? Answer patient is becoming restless Patient with a cerebral aneurysm has a sodium value of 129, what are the causes and clinical signs? Answer SIADH The nurse is monitoring a patients ICP, which intervention is not appropriate if the ICP is steadily increasing? Answer lay the patient in a supine position -Correct: support the patients head and neck with rolled up towels, avoid overhydration, strict I/O monitoring T/F: Patient is S/P craniotomy 4 hours ago, the blood pressure changed from 130/70 to 142/72. Would this indicate a developing complication? Answer True T/F: A patient is 24 hours s/p craniotomy and has decreased responsiveness, would thus require immediate physician notification? False Which of the following s/p craniotomy nursing statements is correct? Extreme head rotation raises ICP T/F: S/P craniotomy, the drain will likely be removed if the serosanguineous drainage is less than 100 mL/day for two days? True A patient enters the emergency department and is diagnosed with traumatic brain injury. What observation will require urgent intervention? urine output of 200mL/h T/F: viruses are the most common causative organisms of brain abscesses? False Which of the following nurse statements is incorrect? corticosteroids have no effect on LOC, mannitol decreases the fluid content of the brain (increasing ICP), corticosteroids reduce tumor inflammation and edema, anticoagulants are contraindicated in all patients with brain tumors The patient has encephalitis, which nursing actions are incorrect? avoid administering opioids, Dilantin PRN for convulsions, encourage visitors to calm the patient -Correct: scheduling/timing patient visits with other disciplines Meningitis outbreaks are most likely to occur in dense community groups such as ___ and ____? college campuses and military installations What is the best protection against meningitis? vaccines @ 11- 12 years of age w/ booster at 16 Which of the following nurse statements about medical treatment of encephalitis is correct? Early administration of antiviral agents improves prognosis, treatment should continue for up to 3 weeks to prevent relapse, acyclovir dosing is adjusted for renal insufficiency Which of the following patient statements about Huntington's would indicate a need for more education? Im going to have to eat through a tube in my stomach -Correct: we can get support from the Huntington's disease society, speech therapy can help me communicate in different ways, I will need to see my care team regularly What myasthenia gravis patient statement about pyridostigmine would indicate a need for more education? this medication will cure my myasthenia gravis -Correct: this medication will last for up to six hours, I will schedule this medication 30 to 60 minutes before I go to work, I will call my doctor if I cant do my usual activities independently Which of the following signs and symptoms may indicate that your patient is experiencing a myasthenia crisis? respiratory distress, dysarthria, dysphagia, diplopia What reported clinical manifestations would you inquire more about a patient with fibromyalgia? trigger points and predictable pain response, sleep disturbances, fatigue, functional impairments A patient has been diagnosed with multiple sclerosis, which statement about activity and rest is incorrect? walking does not improve gait -Correct: take frequent short rest periods preferably lying down, work and exercise to a point just short of fatigue, strenuous physical exercise is not advisable because it will raise body temperature T/F: A patient is newly diagnosed with multiple sclerosis. Encourage exercising during exacerbations to prevent muscle spasms? False Which statement by the nurse would be most appropriate to a patient with ALS, of two years about the disease outcome? most people with ALS die of respiratory failure A patient with a SCI At T1 c/o of a severe headache and an anxious feeling which is the most appropriate initial response? assess for a full bladder S/P MVA, patient is unconscious with the possible SCI. what nursing guidelines will be followed? immobilize the neck using a cervical collar, the patient's head will be secured with a belt or tape secured to sret?, Patient will be placed in a supine position Which statement by the patient requires you to re educate the patient about gullian barre treatment? IG therapies are treatment options when given within four weeks of symptoms -Correct: IG therapy is where IVIG from a donor is given to a patient to stop antibodies, treatment available does not cure the conditions but helps speed up recovery, plasmapheresis well filter my blood to re remove antibodies What would the nurse incorporate in the plan of care to help the client cope with gullian Barre? providing information, giving positive feedback and encouraging relaxation Why would a patient with gullian Barre syndrome need a feeding tube? paralysis of the cranial nerves that affect swallowing Patient with a head injury has vital signs 98./68, which of the following vital signs below should concern you after one hour? a blood pressure of 156/60, pulse 60, respirations 14 The nurse notes that patient has a full thickness circumferential burn on the right leg the nurse would? elevate the leg above the heart level Calculate the TBSA: posterior L arm, back and hand, anterior face, L arm and L thigh 41% What finding below demonstrates the s/p escharotomy procedure was successful? the right foot capillary refill is less than two seconds What is a priority nursing action for a patient in the acute phase of a burn injury? preparing for wound closure A patient has a full thickness burn on the front and back torso, what intervention is appropriate? place the patient in high fowlers, prep the patient for intubation, prep the patient for escharotomy, obtain IV access at two sites A patient is in the emergent/resuscitative burn phase. What lab results would you expect? hyperkalemia, hyponatremia, elevated hematocrit, metabolic acidosis A patient has a chemical burn from lye. Treatment will be based on what knowledge about this burn? this is an alkali burn A patient with septic shock has a UO: 20mL/h x3; HR 120, CVP low, What order will you question? give furosemide 40 milligrams IV A patient is in hypovolemic shock with decreased cardiac output this decreased cardiac output is due to? a decrease in cardiac preload What should these as a priority intervention for a patient who has septic shock? IV fluids to increase intravascular volume The nurse will most likely find which of the following when assessing a client for sepsis? rapid shallow respirations and an elevated temperature Which finding by the nurse will help confirm a diagnosis of neurogenic shock for a patient with massive trauma and SCI? apical heart rate 48 beats per minute Which newly admitted client does the nurse consider to be at highest risk for development of sepsis? a 68 year old woman who is 2 days postoperative from bowel surgery T/F: septic shock causes system wide vasodilation, increased systemic vascular resistance and capillary permeability and micro clots? False A patient is s/p GI surgery: 103.6, 120, 21, 72 / 42 and a high white blood cell count, an IV bolus is given what indicates that the patient is going into septic shock? blood pressure of 70 / 34 after the fluid bolus and needs norepinephrine to maintain a map greater than 65 A patient has septic shock and receives large amounts of IVFs but this was unsuccessful inmaintaining tissue perfusion what should you do next? NE Which statement below best reflects the interventions you will perform for a patient S/P kidney transplant and septic shock? collect cultures and then administer IV antibiotics Which action should the nurse take first for a lung cancer patient who complaints of new onset of back pain? assess for sensation and strength in her legs What is a sign that the surgery and radiation for superior vena cava syndrome is effective? decrease edema You are caring for a patient with lung cancer, what are the physical signs that your patient is developing DIC? increase D dimer, positive guaiac, decrease platelets and tachycardia After change of shift report on the oncology unit which patient should the nurse assess first? patient who is neutropenic and has a temperature of 100.5 The desired outcome for a couple where their wife is having difficulty accepting palliative care for her husband dying is? they acknowledge the symptoms and prognosis What assessment does the nurse perform on a patient with breast cancer on chemo who reports facial edema? examines the clients neck and chest for edema and engorged veins "If I can just live long enough to celebrate my daughter's Sweet 16 I will be ready to die" is an example of? Bargaining The nurse recognizes the need for additional information when a caregiver of a terminally ill patient states? "palliative care interventions hasten death" What is the primary purpose of Hospice? collaborative, holistic support to relieve symptoms The Hospice nurse identifies an abnormal grief reaction by the wife of a dying patient who says: "I dont feel guilty about leaving him to go to lunch with my friends" A patient is in hypovolemic shock, HR 120, BP 80 / 55, urine output 20 milliliters an hour and after an IV bolus what indicates improved perfusion? Urine output increases to 30 milliliters an hour What requires immediate attention for an Ed patient who has multiple injuries from an MVA? deviated trachea A 56 year old patient presents with dizziness and left sided chest pain, the patient should be prioritized into which category? Emergent What phase of Emergency Management includes exercise in drills? Preparedness The nurse is the first responder after a tornado has destroyed many homes, what victim should the nurse attend to 1 st ? child whos complaining my leg is bleeding so bad Im afraid it is A CN must select which patient on her unit can be discharged to make room for victims, who can safely be sent home? the client who 24 hours earlier gave birth to her second baby by C-section During a mass casualty, which injury receives care first? sucking chest wound During a mass casualty, staff rules are defined. If the triage officer is incapacitated who is the next best choice? triage nurse An Ed patient presents with coagulated blood and a white powder and fears that it is an anthrax, what does the nurse do first? Takes the client to the decontamination room After a mass casualty event, care for which of these clients could be delegated to a nursing assistant? a client who is unconscious and has massive aortic bleeding from the chest A 60 year old patient presents to the emergency department after falling off a ladder and is unconscious during the primary survey the nurse should? obtain a Glasgow coma scale score What situation warrants the nurse obtaining information from a material safety data sheet? the custodian spilled a chemical solvent in the hallway The nurse is teaching a class on disaster preparedness, what is not a component of the emergency operations plan? a plan for internal communication only -Correct: practice drills allow for troubleshooting any issues before real-life incident, a deactivation response is important so resources are not overused, a coordinated security plan involving facility and community agencies What statement best describes the role of the medical surgical nurse during a disaster? the nurse may be assigned to the emergency department What is suggested duration of anthrax and biotic treatment by most US health authorities? 60 days What is the rationale for terrorists using news media to report their acts? to spread intimidation and anxiety The following actions are part of the emergency room protocol for possible anthrax exposure or infection what is the priority action? Escort the client to the decontamination area Victims exposed to Botulism are on their way via EMS to your hospital what resources are needed immediately? Antitoxin What statement from your audience would indicate more education is needed about smallpox? it is not contagious and can only be spread by skin to skin -Correct: signs and symptoms include high fever, malaise, headache and backache, it has an incubation of approximately 12 days, smallpox is contagious after the appearance of a rash The person has been exposed to anthrax, which antibiotic can prevent the disease? Ciprofloxacin, levofloxacin, doxycycline Your patient is suspected of having the ebola virus, what action is critical to prevent the virus from spreading? tag teaming during the removal of PPE Which of the following statements are true about ebola? symptomatic patients can spread the disease to others, washing their hands as an effective way to prevent the spread of ebola, clothing with body fluids from an infected person exposes you to ebola T/F: level C protection requires the air purified respirator, chemical resistant coverall with splash hood, gloves and boots? True You would expect to see this injury from a blast wave from a bomb, it is most frequently injury due to the pressure wave? tympanic membrane injury Using principles of triage during a disaster, the nurse should attend to the client with which problem first? bright red bleeding from a neck wound BS-Abx Bacterial meningitis Positive Kernig sign Pt. lies flat and thigh flexed on abdomen - leg unable to completely extend Positive Brudzinski Sign When pt. neck is flexed →knees & hips flex up from straight *More sensitive indicator than kernig Nursing Interventions ICP ↓ Noise/Light Cluster care Limit visitors Pain meds Seizure precautions Monitor LOC, Labs, Urine output Drain CSF (shunt) Priority Nursing Intervention Huntington's w/pneumonia Respiratory support: Incentive Spirometer TCDB (turn cough deep breathe) Humidified O2 CPT Myasthenia gravis treatment Pyridostigmine to improve muscle strength & ADL's Myasthenia Gravis complications missed doses Myasthenic Crisis: Respiratory failure; neuromuscular respiratory failure may require intubation Most common clinical manifestations Fibromyalgia Trigger point pain Difficulty sleeping Nursing Education to prevent injury MS Falls Prevention: Walk with feet apart to widen base Watch feet while walking Gait training Assistive devices (walker, cane, braces Amyotrophic lateral sclerosis (ALS) complication Neuromuscular weakness resulting in respiratory failure that may require intubation Functional ability by Level of Cord Injury C1 - C3 possible C4 Completely dependent for dressing, eating, elimination Electric wheelchair Functional ability by Level of Cord Injury C4 - C5 Maximal Assistance elimination Independent w/ assistance eating/dressing Functional ability by Level of Cord Injury C6 Bowel control Minimal assist in transfers & wheelchair Functional ability by Level of Cord Injury T11 + Ambulatory w/assist Autonomic Dysreflexia Exaggerated autonomic response to stimulation; Triggers: wrinkle in sheets, full bladder pressure, etc. Most common cause of Autonomic Dysreflexia SCI spinal cord injury T6 and above What is seen Guillian-Barre? CSF? Muscle weakness, diminished reflexes, demyelination of nerves Protein in CSF Gullian-Barre nursing interventions Medical emergency due to rapid progression to respiratory failure: Maintain Respiratory & Improve: TCDB, IS, CPT bulbar weakness impairs ability to swallow & clear secretions - suctioning Enhance Mobility: DVT, pressure ulcers Nutrition: prevent ileus, IV fluids Communication Decrease fear & Anxiety Order of Priority Intervention in Burn Patient 1. Obtain VS & hemodynamic status 2. Calculate TBSA affected 3. Calculate Parkland Formula 4. Dress wound w/sterile gauze Third Degree Burns (Full Thickness) Can go into shock Myoglobin urea (muscle breakdown →stuck in kidneys →hematuria) Common in older adults due to ↓ sensation Priority nursing assessments: Emergency/Resuscitative Phase - Burns Airway – intubation Breathing – 100% oxygen (humidified) Circulation – cardiac status Disability - neurologic deficit Expose/examine – burn & other injuries aggressive fluid resuscitation Prevent shock, Respiratory distress Concomitant injuries Wound Assessment Signs and Symptoms: Emergency/Resuscitative Phase Burns Tachycardia Tachypnea Hypovolemia Edema Electrolyte disturbance: ↑K cardiac monitor Wound Debridement 4 Types Natural – by body, takes weeks to months proteolytic enzymes gradually separate the collagen holding eschar in place Mechanical – uses surgical tools, done at bedside Surgical tools to separate & remove eschar; daily dressing changes (not wet to dry) Chemical – enzymatic agents, promote debridement (note antibacterial) Surgical – anesthesia, grafts; early surgery excision very important for survival major burn injury Performed once edema decreased & pt. is stable; generally shorter length of stay, decreased risk of complications/sepsis. Signs and Symptoms of Compartment Syndrome Emergent situation: ↑in pain, numbness or tingling, severe edema, ↓ pulses below site Deep, throbbing, unrelenting pain - Assess the 5 P's: pain, pallor, pulselessness, paresthesia, and paralysis Hypovolemic Shock interventions Fluid volume replacement (0.9% NaCl/NS or LR) Hemodynamic monitoring (CVP) Meds as prescribed Oxygen Signs and symptoms: Septic Shock ↓ BP hyperthermia bounding pulses ↑ RR ↓ Urine OP Organ failure Kussmaul's shallow & rapid breathing Vasodilation Septic Shock Patho Precipitating event →Vasodilation →Inflammatory response →Maldistribution of intravascular volume → ⇩venous return → ⇩ cardiac output → ⇩ tissue perfusion Priority Treatments for Hypovolemic shock Fix underlying cause Fluid volume replacement hemodynamic monitoring CVP medications as prescribed oxygen Septic Shock Priority ? Assess Vitals 1st Sepsis Bundle Complete in first 3 hours: lactate level blood culture broad spectrum antibiotics aggressive fluid resuscitation Complete ASAP or within 6 hours: Begin vasopressors if hypotension not improved & MAP 65 after fluids (norepinephrine) Measure Scv O2 CVP (goal 8-12) normal 2-6 Fluid Challenge Stages of Shock 1. Compensatory: VS changes, Acidosis, Neuro Changes 2. Progressive: Resp. changes, a. Kussmaul’s (shallow and rapid) *NOT DEEP BREATHS* ? b. ALI (Acute Lung Injury), Dysrhythmias, LOC changes, Renal, Hepatic changes c. UOP less that 0.5 mL/kg/hr 3. Irreversible: BP hypotension, Renal, liver, Resp dysfunction, MODS, Death a. No UOP, intubated, unconscious Signs and symptoms: Tumor Lysis Syndrome Radiation/Chemo cells lyse Cell destruction →release of intracellular electrolytes → ↑ acid, ↑ K+, ↑ phosphorus, ↓ Calcium K+ muscular weakness, paralysis, N, dysrhythmias Phos twitching, tingling, numbness, muscle cramps, irritability & joint pain Calcium muscle aches, bronchospasm, seizures, tetany +Trousseau’s & Chvostek’s Acidosis N/V fatigue, headache, confusion, breathing rapid, shallow, slow or both Treatment: Tumor Lysis Syndrome IV fluid Hemodialysis Loop Diuretics Allopurinol Kayexalate Kubler-Ross Stages of Grief Denial Anger Bargaining Depression Acceptance Criteria for Hospice Care Serious, progressive illness (irreversible) Life expectancy 6 months Informed choice of palliative care over cure-focus treatment What is palliative care? Comfort care Symptom management Psychosocial support Spiritual support Communication Orientation Mindfulness Family Openness Relating Team Oncologic Emergencies Cause: Sepsis related to neutropenia or hematologic malignancy Oncologic Emergencies Cause: DIC Clot - bleed - clot - bleed until clotting factors used up Related to lung cancer High mortality rate Describe tagging system in Mass Casualty Events Name Age Description Location found Any Tx in field Emergency Management Priority 1. Establish patent airway 2. Stop bleeding 3. Insert IV 4. CT scan Victim Violence/domestic abuse protection in ER Give pt. an alias Triage nurse - you have to state the risk they are 1. High: cardiac arrest STEMI 2. Medium: Diabetes, Concerning Symptoms, newly rising troponin 3. Low: decreasing troponin, Low-risk presentation S/S Hospital Incident Command System HICS: Distribution of resources Greatest Good for the Greatest Number Nurse Duty according to The Joint Commission Nonmaleficence Beneficence Distributive Justice PPE 1. Level D Standard/typical work uniform 2. Level C Air purified respiratory, think Covid 3. Level B Similar to A but not vapor tight 4. Level A Think ebola Highest level of protection, Including self-contained breathing apparatus, Chemical-resistant suit/gloves, vapor-tight Most Common injury Weapons of terror: Bombs Blast lung, Blast tympanic membranes, tearing of tissue, hemorrhage a. Air emboli L lung on lateral side Nursing precautions for caring for a violent, restrained patient. Handcuffed to bed guard in room mask if spitting distance self between door Exit Route No hanging objects (stethoscope, jewelry) Resources available for pt. after discharge to refer pt. to? Case manager Social worker ER Triage System 1. High: cardiac arrest STEMI 2. Medium: Diabetes, Concerning Symptoms, newly rising troponin 3. Low: decreasing troponin, Low-risk presentation S/S Four Colors of Triage for Mass Casualty Incidents Priority/Immediate Red: Sucking chest wound, airway obstructions secondary to mechanical cause, shock, hemothorax, tension pneumothorax, asphyxia, unstable chest/abdominal wounds Delayed Yellow: stable abdominal wounds, soft tissue injuries, fractures, most eye injuries Minimal Green: minor burns, sprains, behavioral disorders, small lacerations Expectant Black: unresponsive with penetrating head wound, high spinal cord injury; chances of survival are unlikely Education to family/patient with smallpox Individuals with face-to-face contact after fever begins should be vaccinated within 4 days. Nursing interventions: Treating pt. with botulism Standard precautions Antitoxin immediately before diagnostic results Penicillin Antibiotics not recommended for infants PPE procedures when caring for a patient with Ebola PPE buddy; Level A precautions: self-contained breathing apparatus SCBA, vapor tight Traumatic Brain Injury TBI Protein in CSF Risk of ↑ ICP Diabetes Insipidus Dolls Eyes Signs & Symtoms: ICP Headache Vomiting Earliest sign change in LOC Blurry vision Unequal pupils a. Decortication: abnormal flexion of upper extremities & extension of lower extremities i. Arms toward core b. Decerebration: extreme extension of upper and lower extremities i. *worst arms toward outwards Interventions: Decrease ICP Elevate HOB Osmotic diuretic (mannitol) Restrict fluids Drain CSF Control fever Maintain BP & Oxygenation WNL CPP (cerebral perfusion pressure) Greater than 50 mm Hg normal Post-Op Complications: Craniotomy 1. ↑ ICP 2. Bleeding or Hypovolemic Shock 3. Fluid & Electrolyte 4. Infection 5. CSF Leaks 6. Seizures Meningitis type HIV/AIDS susceptible Cryptococcal Meningitis Risks & Prevention: Meningitis Prevention: Vaccine 11/12 yr and booster at 16 Risks: Unvaccinated 1st year college students & military Close contact w/meningococcal Meningitis Prophylaxis treatment w/24 hrs Rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin) Rule of 9's for burns Head 9% Anterior Trunk 18% Posterior Trunk 18% Arm (whole arm) 9% Legs (whole leg) 18% Pubic area 1%