Complex Adult Health CMS review QUESTIONS AND ANSWERS A GRADED
Modifiable vs non modifiable risk factors Correct Answer: Modifiable: can be changed
- smoking, nutrition, access to health education, sexual practices and exercise
Nonmodifiable: cannot be changed
- sex, age, race, developmental level and genetic traits
ABCDEFGHI Principle Correct Answer: Airway/cervical spine
Breathing
Circulation
Disability
Examine
Fahrenheit
Get vitals
Heat to toe
Interventions
Immediate interventions for loss of airway Correct Answer: Loss of ability to maintain an airway -
inspect for things causing an obstruction
If unresponsive without suspicion of trauma - open airway using head-tilt, chin-lift maneuver
If unresponsive with suspicion of trauma - open airway with a modified jaw thrust maneuver
What type of oxygen delivery device would be used for clients needing additional support during
resuscitation until advanced airway is established? Correct Answer: Bag-valve mask with a 100% oxygen
source
Interventions for restoring effective circulation Correct Answer: - CPR
- assess for external bleeding
- hemorrhage control
- IV access using large bore catheters
- infuse isotonic IV fluids
If a client is not breathing or is breathing inadequately what should be done in terms of oxygenation?
Correct Answer: Manual ventilation by a bag valve mask with supplemental oxygenation
Early signs of shock Correct Answer: - MAP down 10mmHg fr. baseline
- effective compensation of O2 --> vital organs
- increased HR
Compensatory signs of shock Correct Answer: - MAP down 10-15 mmHg fr. baseline
- Increase renin
- Increase ADH
- vasoconstriction
- decrease pulse pressure
- increase HR
- decrease pH
,- restless
- apprehensive
Progressive signs of shock Correct Answer: - MAP decrease 20 mmHg fr. baseline
- Tissue/Organ hypoxia
- decrease urine (oliguria)
- weak rapid pulse
- decrease pH
- sensory neural changes
Refractory signs of shock Correct Answer: - excessive cellorgan damage
- multi system organ failure
- decrease pH
What can develop if circulation is compromised as the body's response to inadequate tissue perfusion
and oxygenation? Correct Answer: Shock
Interventions to alleviate shock Correct Answer: -administering oxygen
-Apply pressure to obvious bleeding
-Elevate lower extremities to shunt blood to vital organs
-AdministerIV fluids & blood products as ordered
-Monitor VS
-Remaining w/ the client & provide reassurance & support for anxiety
AVPU mnemonic Correct Answer: *AVPU mnemonic - to assess the "D"/Disability in the Primary ABCDE
Assessment*
- A, alert: is the client alert and responsive?
- V, verbal: does the client respond to verbal stimuli?
- P, pain: does the client respond only to painful stimuli?
- U, unresponsive: is the client unresponsive to all stimuli, including pain?
Glasgow Coma Scale (GCS) Correct Answer: Eye opening: 1) none, 2) to pain, 3) to verbal command, 4)
spontaneous
Verbal response: 1) none, 2) incomprehensible sounds, 3) inappropriate words, 4) disoriented/confused,
5) oriented
Motor response: 1) none, 2) decerebrate, 3) decorticate, 4) withdraws to pain, 5) localizes pain, 6) obeys
commands
Arterial line monitoring Correct Answer: Continuous BP & blood specimens for ABGs
Pulmonary artery catheter monitoring Correct Answer: Central venous pressure
Pulmonary artery pressure
Cardiac output
**Continuous hemodynamic monitoring**
, What position should a patient with shock or hypotension be placed in? Correct Answer: Flat with both
legs elevated
Degrees of frostbite Correct Answer: 1st degree- superficial layers of exposed skin, hyperemia & edema
2nd degree- blister cover exposed skin causing necrotic tissue death and swelling
3rd degree- extensive edema & blisters that don't blanch, treated with debridement of damaged tissue
4th degree- area lacks blood supply, full thickness necrosis of skin with potential progression to
gangrene
Nursing care for frostbite Correct Answer: Bathing affected areas in warm bath (104° to 108°) improves
blood circulation
- rewarming can increase pain to affected areas
Administer tetanus toxoid IM vaccine
Nursing care to prevent hypothermia Correct Answer: - remove wet clothing
- cover with warm blankets
- increase room temp
- use heat lamp to provide warmth
- infuse warmed IV fluids
Heat stroke Correct Answer: Medical emergency requiring immediate treatment
- administer O2 as needed
- large gauge IV for 0.9% sodium chloride
- may require in dwelling urinary catheter
- apply ice packs and cooling blankets
Nursing care for poisoning Correct Answer: Prevent further absorption of toxin
Respiratory support
Circulation and restore fluids
Monitor ABGs
Ingested poisoning may need activated charcoal, gastric lavage, or aspiration
Snake bite/ Spider bite: antivenom within 4-12 hr
> assess tissue for edema q15 to 30 min
> opioid meds for pain
Reverse heroin and other opiate toxicity with... Correct Answer: Naloxone
Common causes of pulseless electrical activity Correct Answer: 5 H's
Hypovolemia
Hypoxia
Hydrogen ion accumulation, resulting in acidosis
Hyperkalemia
Hypothermia
5 T's
Toxins
Tamponade (cardiac)
Tension pneumothorax
Modifiable vs non modifiable risk factors Correct Answer: Modifiable: can be changed
- smoking, nutrition, access to health education, sexual practices and exercise
Nonmodifiable: cannot be changed
- sex, age, race, developmental level and genetic traits
ABCDEFGHI Principle Correct Answer: Airway/cervical spine
Breathing
Circulation
Disability
Examine
Fahrenheit
Get vitals
Heat to toe
Interventions
Immediate interventions for loss of airway Correct Answer: Loss of ability to maintain an airway -
inspect for things causing an obstruction
If unresponsive without suspicion of trauma - open airway using head-tilt, chin-lift maneuver
If unresponsive with suspicion of trauma - open airway with a modified jaw thrust maneuver
What type of oxygen delivery device would be used for clients needing additional support during
resuscitation until advanced airway is established? Correct Answer: Bag-valve mask with a 100% oxygen
source
Interventions for restoring effective circulation Correct Answer: - CPR
- assess for external bleeding
- hemorrhage control
- IV access using large bore catheters
- infuse isotonic IV fluids
If a client is not breathing or is breathing inadequately what should be done in terms of oxygenation?
Correct Answer: Manual ventilation by a bag valve mask with supplemental oxygenation
Early signs of shock Correct Answer: - MAP down 10mmHg fr. baseline
- effective compensation of O2 --> vital organs
- increased HR
Compensatory signs of shock Correct Answer: - MAP down 10-15 mmHg fr. baseline
- Increase renin
- Increase ADH
- vasoconstriction
- decrease pulse pressure
- increase HR
- decrease pH
,- restless
- apprehensive
Progressive signs of shock Correct Answer: - MAP decrease 20 mmHg fr. baseline
- Tissue/Organ hypoxia
- decrease urine (oliguria)
- weak rapid pulse
- decrease pH
- sensory neural changes
Refractory signs of shock Correct Answer: - excessive cellorgan damage
- multi system organ failure
- decrease pH
What can develop if circulation is compromised as the body's response to inadequate tissue perfusion
and oxygenation? Correct Answer: Shock
Interventions to alleviate shock Correct Answer: -administering oxygen
-Apply pressure to obvious bleeding
-Elevate lower extremities to shunt blood to vital organs
-AdministerIV fluids & blood products as ordered
-Monitor VS
-Remaining w/ the client & provide reassurance & support for anxiety
AVPU mnemonic Correct Answer: *AVPU mnemonic - to assess the "D"/Disability in the Primary ABCDE
Assessment*
- A, alert: is the client alert and responsive?
- V, verbal: does the client respond to verbal stimuli?
- P, pain: does the client respond only to painful stimuli?
- U, unresponsive: is the client unresponsive to all stimuli, including pain?
Glasgow Coma Scale (GCS) Correct Answer: Eye opening: 1) none, 2) to pain, 3) to verbal command, 4)
spontaneous
Verbal response: 1) none, 2) incomprehensible sounds, 3) inappropriate words, 4) disoriented/confused,
5) oriented
Motor response: 1) none, 2) decerebrate, 3) decorticate, 4) withdraws to pain, 5) localizes pain, 6) obeys
commands
Arterial line monitoring Correct Answer: Continuous BP & blood specimens for ABGs
Pulmonary artery catheter monitoring Correct Answer: Central venous pressure
Pulmonary artery pressure
Cardiac output
**Continuous hemodynamic monitoring**
, What position should a patient with shock or hypotension be placed in? Correct Answer: Flat with both
legs elevated
Degrees of frostbite Correct Answer: 1st degree- superficial layers of exposed skin, hyperemia & edema
2nd degree- blister cover exposed skin causing necrotic tissue death and swelling
3rd degree- extensive edema & blisters that don't blanch, treated with debridement of damaged tissue
4th degree- area lacks blood supply, full thickness necrosis of skin with potential progression to
gangrene
Nursing care for frostbite Correct Answer: Bathing affected areas in warm bath (104° to 108°) improves
blood circulation
- rewarming can increase pain to affected areas
Administer tetanus toxoid IM vaccine
Nursing care to prevent hypothermia Correct Answer: - remove wet clothing
- cover with warm blankets
- increase room temp
- use heat lamp to provide warmth
- infuse warmed IV fluids
Heat stroke Correct Answer: Medical emergency requiring immediate treatment
- administer O2 as needed
- large gauge IV for 0.9% sodium chloride
- may require in dwelling urinary catheter
- apply ice packs and cooling blankets
Nursing care for poisoning Correct Answer: Prevent further absorption of toxin
Respiratory support
Circulation and restore fluids
Monitor ABGs
Ingested poisoning may need activated charcoal, gastric lavage, or aspiration
Snake bite/ Spider bite: antivenom within 4-12 hr
> assess tissue for edema q15 to 30 min
> opioid meds for pain
Reverse heroin and other opiate toxicity with... Correct Answer: Naloxone
Common causes of pulseless electrical activity Correct Answer: 5 H's
Hypovolemia
Hypoxia
Hydrogen ion accumulation, resulting in acidosis
Hyperkalemia
Hypothermia
5 T's
Toxins
Tamponade (cardiac)
Tension pneumothorax
