MDC 4 NUR2755 FINAL EXAM Solution Bank.
MDC 4 NUR2755 FINAL EXAM What does triaging do? (correct ANS)- *acts as gatekeeper* helps prioritize patient care based on illness and severity level According to triage, what patients would be seen firtst (correct ANS)- highest acuity patients will receive quickest intervention (Most ill/severe will get seen first) What is a good model for triaging patients? (correct ANS)- ABCs Is hospital triaging the same as mass casualty triaging? (correct ANS)- NO Which triage situation uses tags? (correct ANS)- mass casualties what are the categories of triage? (correct ANS)- - emergent - urgent - nonurgent - primary survey what classifies a patient as emergent according to triage (correct ANS)- - life threatening injuries - needs immediate treatment what patient conditions warrant an emergent status of triage (correct ANS)- - respiratory distress - chest pain with diaphoresis - stroke - active hemorrhage - unstable vitals what classifies a patient as urgent according to triage (correct ANS)- patient should be treated quickly but there is not and immediate threat to life what patient conditions warrant an urgent status for triage (correct ANS)- - severe abdominal pain - renal colic - displaced multiple fractures - new onset of respiratory infection (pneumonia) what classifies a patient as nonurgent according to triage (correct ANS)- patient can wait several hours without a risk to life what patient conditions warrant a nonurgent status for triage (correct ANS)- - skin rash - strains/sprains - colds - simple fracture what is a primary survey that should be performed while triaging? (correct ANS)- ABCDE what does ABCDE stand for in triaging patients (correct ANS)- A: Airway/cervical spine B: Breathing C: Circulation D: Disability E: Exposure what does the "A" refer to in ABCDE (correct ANS)- airway, cervical spine - patent airway - immobilize spine **do NOT move patient what does the "B" refer to in ABCDE (correct ANS)- breathing - assess sounds - assess chest wall movement what does the "C" refer to in ABCDE (correct ANS)- circulation - vitals (BP and pulse) - maintain vascular access - stop any bleeding what does the "D" refer to in ABCDE (correct ANS)- disability *LOC what does the "E" refer to in ABCDE (correct ANS)- exposure - get clothes off - use blankets to prevent hypothermia what is the one exception to ABCDE? (correct ANS)- in excessive bleeding, you would prioritize "C" before "AB" what is a secondary survey? (correct ANS)- comprehensive head to toe assessment if warranted during the secondary survey, what would a nurse likely do? (correct ANS)- - insert NG tube - insert catheter - prep for diagnostics what does drowning lead to? (correct ANS)- leads to loss of surfactant in lungs which causes alveolar collapse and pulmonary edema is dehydration common in heat exhaustion? (correct ANS)- YES what can major diaphoresis cause? (correct ANS)- severe dehydration and hyponatremia if heat exhaustion goes untreated, what can it cause? (correct ANS)- heat stroke what are the s/s of heat exhaustion (correct ANS)- -dehydration -decrease in blood volume -decrease in BP -tachycardia what is the first intervention for a person expected to have heat exhaustion? (correct ANS)- stop their physical activity and transfer to a cool place what is the quickest way to reduce someone's temperature? (correct ANS)- - remove clothing - remove bed linen what interventions are there for cooling patients down? (correct ANS)- - cold pack on the neck, chest, abdomen, and groin - soak in cool water when rehydrating someone with heat exhaustion, should you use water or a sports drink/oral reydration solution? (correct ANS)- Sports drink/oral hydration solution why is a sports drink better at rehydrating patients with heat exhaustion? (correct ANS)- plain water can worsen sodium deficits nursing care for patients hospitalized with heat exhaustion (correct ANS)- - monitor vitals - administer .9% NS in N/V is present - draw labs to check electrolytes how is heat stroke defined? (correct ANS)- body temperature greater than 104F T/F: heat stroke is a medical emergency (correct ANS)- TRUE T/F: if heat stroke is left untreated it becomes fatal (correct ANS)- TRUE s/s of heat stroke (correct ANS)- - tachycardia - hallucinations - irregular pulse - decreased urin output - hot and dry skin nursing care for heat stroke (correct ANS)- - 02 and .9% NS via IV - continuous cooling, IVF, and cooling blankets. when should continuous cooling, IVF, and cooling blankets be stopped? (correct ANS)- when core temperature reaches 102F what should you do if your patient is shivering while being cooled from heat stroke? (correct ANS)- administer benzos because they provide sedation, control convulsions, and control shivering what should you NOT administer for a person with a high body temperature (correct ANS)- - aspirin - antipyretics at what temperature does hypothermia occur? (correct ANS)- less than 95F nursing care for hypothermia (correct ANS)- - find shelter away from cold - remove wet clothing - monitor for cardio issues, ARDS, pneumonia - focus on rewarming slowly in hypothermia, why should cardo issues be monitored? (correct ANS)- dysrhythmias could result from lactic acid build up what is frostbite (correct ANS)- freezing of body tissue how many degrees of frostbite are there? (correct ANS)- 4 what happens with 1st degree frostbite? (correct ANS)- hyperemia and edema (hyperemia: increased blood flow) what happens with 2nd degree frostbite? (correct ANS)- - red area - blisters with clear/milky fluid - partial thickness necrosis what happens with 3rd degree frostbite (correct ANS)- - small blisters with dark fluid - body is cold, numb, blue/red, and NO blanching what happens with 4th degree frostbite? (correct ANS)- - NO blisters or edema - numb, cold, bloodless - in muscle and bone what happens when frostbite reaches the muscle and bone? (correct ANS)- gangrene (4th degree frostbite) how is a person warmed after frostbite? (correct ANS)- rapid rewarming with a water bath that's temperature is 104-108F how is a frostbit injury handled after rewarming has taken place? (correct ANS)- injury should be handled above heart level nursing care of frostbite (correct ANS)- - pain control with analgesics and IV rehydration - loose, non adherent sterile dressings what pain medication should be used for frostbite? (correct ANS)- IV opiates T/F: for a person with frostbite, the nurse should tightly wrap the patients wound (correct ANS)- FALSE **compression should be avoided what are arthropods (correct ANS)- - spiders - scorpions - bees - wasps nursing care for a patient injured by an arthropod (correct ANS)- - remove stinger - cold compress - Epi pen and oxygen for anaphylaxis what is affected by a lightning injury? (correct ANS)- heart and CNS who is most at risk for a lightning injury (correct ANS)- young adult males what nursing care is needed for a lightning injury (correct ANS)- - immediate CPR - ECG - CT - tetanus prophylaxis what system is used during a mass casualty to sort patients into priority of care? (correct ANS)- tag system what information do you write on the triage tags? (correct ANS)- - color/priority - age/DOB (identifying characteristics) - treatment and meds already given - next of kin what is the color system for triage tagging (correct ANS)- - green - yellow - red - black what does the color green mean in triage? (correct ANS)- non-urgent/walking, talking what does yellow mean in triage (correct ANS)- urgent but not life threatening what does the red tag mean in triage (correct ANS)- emergent could die if not treatment but have better odds what does black mean in triage (correct ANS)- do not attempt to treat them because their injuries are too extensive and will die regardless interventions to manage stress (correct ANS)- - develop a buddy system w/ coworker - have well balanced meals - drink alot of water - take breaks - do not exceed more than 12hrs/day - stay in touch with friends/family - crisis debriefing - take a few minutes each shift to decompress MRC (correct ANS)- Medical Reserve Corps why is MRC a thing? (correct ANS)- Created for volunteers in the community who want to donate their time ad expertise to prepare for and respond to emergencies on a local scale DMAT (correct ANS)- Disaster Medical Assistance Team what does DMAT do (correct ANS)- they are federal employees who make up a medical relief team made up of civilians who's license is valid in all states when working how can a person be prepared for disasters (correct ANS)- have a go bag with personal readiness supplies **should be enough for three days at least what is an internal disaster (correct ANS)- anything impacting inside the hospital examples of an internal disaster (correct ANS)- - fire - water pipe burst - power outage - shooting at Seattle Grace what is an external disaster (correct ANS)- A disaster that occurs in the community and may be natural, manmade, or terror-induced examples of external disasters (correct ANS)- - earthquake - flood - car pile up - ferry boat crash What is the most common type of dementia? (correct ANS)- Alzheimer's disease Is Alzheimer's reversible? (correct ANS)- No What is the etiology of Alzheimer's? (correct ANS)- Unknown Alzheimer's is the result of? (correct ANS)- changes in personality, memory, and/or judgement What are risk factors for Alzheimer's? (correct ANS)- * 65+ years * female * head injury * APOE gene what is the patho of Alzheimer's (correct ANS)- plaques, tangles, degeneration of neurons How is Alzheimer's diagnosed? (correct ANS)- biopsy at autopsy is the only definitive way but dementia can be ruled out with CT, labs, UA, and MRI Early s/s of Alzheimer's Disease (correct ANS)- - decreased short term memory - decreased sense of smell - misplaced items Middle s/s of Alzheimer's Disease (correct ANS)- - wander - agitated - incontinent - money issues late s/s of Alzheimer's disease (correct ANS)- - bed ridden - agnosia (inability to recognize objects, people, or sounds) Medications used for Alzheimer's (correct ANS)- Cholinesterase inhibitors - slow breakdown of Ach - Donepezil and Rivastigimine NMDA receptor antagonists - block excess amounts of glutamate - Memantine Nursing care for Alzheimer's (correct ANS)- - safe environment (#1) good lighting, no clutter - stick with a routine - offer walks, exercise - reduce distractions - avoid use of restraints What is Parkinson's Disease (correct ANS)- Movement disorder caused by the death of cells that generate dopamine in the basal ganglia and substantial nigra. *************************CONTINUED**********************
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