NUR 265 TEST 3
What causes Autonomic Dysreflexia - answers Stimulation at level of T6 or above
What are some examples of triggers of autonomic dysreflexia - answers restrictive
clothing; full bladder/neurogenic bladder; fecal impaction; directive pressure s/a sitting in
the wheel chair
signs and systems of Autonomic Dysreflexia - answers 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 - answers 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 - answers Lactated
ringers
Chemical burns should be irrigated until - answers 20 minutes or the burn sensation
continues after the 20 minute marker
what would you use to remove hot tar or asphalt - answers 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 - answers cortical and premotor cortex damage
what kind of brain injury would you expect if an adult client is positive for plantar infant
reflexes - answers upper motor neuron lesion
what kind of brain injury would you expect if an adult client is positive for rooting infant
reflex - answers frontal lobe damage
what kind of brain injury would you expect if an adult client is positive for sucking infant
reflex - answers 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 - answers diffuse cortical dysfunction
What is the consensus formula for burns - answers 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 - answers Restlessness, anxiety, Hypothermia
how much fluid replacement are you going to give the first 8 hours - answers 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 - answers Urine output
Besides a hyperbaric chamber how would you admin o2 to a client with CO poisoning -
answers 100% O2 with a non-rebreather
How would you treat a circumferential trunk burn that is swelling and why? - answers
Eschartomies R/T constriction of the chest wall expansion
what are the classification of shock - answers Cardiogenic; hypovolemic, neurogenic,
and Disruptive
All shock is caused by - answers inadequate tissue perfusion
Patho of hypovolemic shock - answers Inadequate circulating blood volume S/A burns,
hemorrhage, dehydration
Patho for cardiogenic shock - answers Inadequate pumping action of the heart S/A MI,
CHF, PE
What are the 3 subclasses of Distributive shock - answers Anaphylactic; Septic;
Neurogenic
Patho for neurogenic shock - answers interference of the nervous system that controls
the blood vessels
Patho for septic shock - answers 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
- answers 15-25%, or 1/3 of the body blood, or 5L
clients who experience slow blood loss can - answers Tolerate the blood loss better
then a client with rapid blood loss
, Signs and symptoms of compensatory shock - answers hypotension, tachycardia,
tachypnea, hypothermia, decrease pulse pressure
During compensatory stage of shock, why would you hear hypoactive bowl sounds and
cool and clammy skin - answers 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 - answers High
production of aldosterone
why do RR increase in compensatory stage of shock - answers 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 - answers Lactic acid, Compensatory
Why would you not give someone with impaired hepatic function lactated ringers -
answers 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 - answers 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 - answers progressive
What happends to the body when build up of lactic acid occurs - answers increase
capillary permeability; relaxation of capillary spincter; blood is retaining in the cap beds
S&S of the progressive stage of shock - answers Hypoxia, alveolar collapse, pulmonary
edema, cardiac dysrhythmias, ischemic heart, ARF, DIC, Mental status change
Patho of the progressive stage of shock - answers organ suffering from hypoxia,
vasoconstriction decrease cell perfusion, GFR cannot be maintained
How do you calculate MAP - answers Systolic (2 X diastolic) / 3
Manis of shock - answers 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 - answers SIRS
S&S of Hypovolemic shock - answers 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)
What causes Autonomic Dysreflexia - answers Stimulation at level of T6 or above
What are some examples of triggers of autonomic dysreflexia - answers restrictive
clothing; full bladder/neurogenic bladder; fecal impaction; directive pressure s/a sitting in
the wheel chair
signs and systems of Autonomic Dysreflexia - answers 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 - answers 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 - answers Lactated
ringers
Chemical burns should be irrigated until - answers 20 minutes or the burn sensation
continues after the 20 minute marker
what would you use to remove hot tar or asphalt - answers 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 - answers cortical and premotor cortex damage
what kind of brain injury would you expect if an adult client is positive for plantar infant
reflexes - answers upper motor neuron lesion
what kind of brain injury would you expect if an adult client is positive for rooting infant
reflex - answers frontal lobe damage
what kind of brain injury would you expect if an adult client is positive for sucking infant
reflex - answers 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 - answers diffuse cortical dysfunction
What is the consensus formula for burns - answers 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 - answers Restlessness, anxiety, Hypothermia
how much fluid replacement are you going to give the first 8 hours - answers 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 - answers Urine output
Besides a hyperbaric chamber how would you admin o2 to a client with CO poisoning -
answers 100% O2 with a non-rebreather
How would you treat a circumferential trunk burn that is swelling and why? - answers
Eschartomies R/T constriction of the chest wall expansion
what are the classification of shock - answers Cardiogenic; hypovolemic, neurogenic,
and Disruptive
All shock is caused by - answers inadequate tissue perfusion
Patho of hypovolemic shock - answers Inadequate circulating blood volume S/A burns,
hemorrhage, dehydration
Patho for cardiogenic shock - answers Inadequate pumping action of the heart S/A MI,
CHF, PE
What are the 3 subclasses of Distributive shock - answers Anaphylactic; Septic;
Neurogenic
Patho for neurogenic shock - answers interference of the nervous system that controls
the blood vessels
Patho for septic shock - answers 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
- answers 15-25%, or 1/3 of the body blood, or 5L
clients who experience slow blood loss can - answers Tolerate the blood loss better
then a client with rapid blood loss
, Signs and symptoms of compensatory shock - answers hypotension, tachycardia,
tachypnea, hypothermia, decrease pulse pressure
During compensatory stage of shock, why would you hear hypoactive bowl sounds and
cool and clammy skin - answers 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 - answers High
production of aldosterone
why do RR increase in compensatory stage of shock - answers 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 - answers Lactic acid, Compensatory
Why would you not give someone with impaired hepatic function lactated ringers -
answers 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 - answers 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 - answers progressive
What happends to the body when build up of lactic acid occurs - answers increase
capillary permeability; relaxation of capillary spincter; blood is retaining in the cap beds
S&S of the progressive stage of shock - answers Hypoxia, alveolar collapse, pulmonary
edema, cardiac dysrhythmias, ischemic heart, ARF, DIC, Mental status change
Patho of the progressive stage of shock - answers organ suffering from hypoxia,
vasoconstriction decrease cell perfusion, GFR cannot be maintained
How do you calculate MAP - answers Systolic (2 X diastolic) / 3
Manis of shock - answers 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 - answers SIRS
S&S of Hypovolemic shock - answers 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)
