NUR 265 – Test 3 – Nursing Concepts III – Complete Exam Study Guide
(Autonomic Dysreflexia, Burns, Shock, Brain Injuries, MODS)
What causes Autonomic Dysreflexia - correct answer Stimulation at level of T6 or above
What are some examples of triggers of autonomic dysreflexia - correct answer restrictive
clothing; full bladder/neurogenic bladder; fecal impaction; directive pressure s/a sitting in the
wheel chair
signs and systems of Autonomic Dysreflexia - correct answer 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 - correct answer 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 - correct answer Lactated
ringers
Chemical burns should be irrigated until - correct answer 20 minutes or the burn sensation
continues after the 20 minute marker
what would you use to remove hot tar or asphalt - correct answer 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 - correct answer cortical and premotor cortex damage
what kind of brain injury would you expect if an adult client is positive for plantar infant
reflexes - correct answer upper motor neuron lesion
what kind of brain injury would you expect if an adult client is positive for rooting infant reflex -
correct answer frontal lobe damage
what kind of brain injury would you expect if an adult client is positive for sucking infant reflex -
correct answer 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 - correct answer diffuse cortical dysfunction
What is the consensus formula for burns - correct answer 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 -
correct answer Restlessness, anxiety, Hypothermia
how much fluid replacement are you going to give the first 8 hours - correct answer 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 - correct answer Urine output
Besides a hyperbaric chamber how would you admin o2 to a client with CO poisoning - correct
answer 100% O2 with a non-rebreather
How would you treat a circumferential trunk burn that is swelling and why? - correct answer
Eschartomies R/T constriction of the chest wall expansion
what are the classification of shock - correct answer Cardiogenic; hypovolemic, neurogenic, and
Disruptive
All shock is caused by - correct answer inadequate tissue perfusion
Patho of hypovolemic shock - correct answer Inadequate circulating blood volume S/A burns,
hemorrhage, dehydration
Patho for cardiogenic shock - correct answer Inadequate pumping action of the heart S/A MI,
CHF, PE
What are the 3 subclasses of Distributive shock - correct answer Anaphylactic; Septic;
Neurogenic
Patho for neurogenic shock - correct answer interference of the nervous system that controls
the blood vessels
Patho for septic shock - correct answer 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 -
correct answer 15-25%, or 1/3 of the body blood, or 5L
clients who experience slow blood loss can - correct answer Tolerate the blood loss better then
a client with rapid blood loss
Signs and symptoms of compensatory shock - correct answer hypotension, tachycardia,
tachypnea, hypothermia, decrease pulse pressure
During compensatory stage of shock, why would you hear hypoactive bowl sounds and cool and
clammy skin - correct answer 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 - correct answer High
production of aldosterone
why do RR increase in compensatory stage of shock - correct answer 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 -
correct answer Lactic acid, Compensatory
Why would you not give someone with impaired hepatic function lactated ringers - correct
answer 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 -
correct answer 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 - correct answer progressive
What happends to the body when build up of lactic acid occurs - correct answer increase
capillary permeability; relaxation of capillary spincter; blood is retaining in the cap beds
S&S of the progressive stage of shock - correct answer Hypoxia, alveolar collapse, pulmonary
edema, cardiac dysrhythmias, ischemic heart, ARF, DIC, Mental status change
Patho of the progressive stage of shock - correct answer organ suffering from hypoxia,
vasoconstriction decrease cell perfusion, GFR cannot be maintained
How do you calculate MAP - correct answer Systolic (2 X diastolic) / 3
Manis of shock - correct answer 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 - correct answer SIRS
S&S of Hypovolemic shock - correct answer 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)
Pt with a hernia repair comes back post op VS; 99/50 HR; 115 RR; 28, Pain 5 O2 89% - What
would you do first - correct answer 1) Treat O2 levels by Raising HOB and applying O2
2) Treat hypotension; Fluid replacement (LR)
3) manage pain
What will determine what you would do for your patient first - correct answer the results of
your head to toe assessment.
(Autonomic Dysreflexia, Burns, Shock, Brain Injuries, MODS)
What causes Autonomic Dysreflexia - correct answer Stimulation at level of T6 or above
What are some examples of triggers of autonomic dysreflexia - correct answer restrictive
clothing; full bladder/neurogenic bladder; fecal impaction; directive pressure s/a sitting in the
wheel chair
signs and systems of Autonomic Dysreflexia - correct answer 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 - correct answer 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 - correct answer Lactated
ringers
Chemical burns should be irrigated until - correct answer 20 minutes or the burn sensation
continues after the 20 minute marker
what would you use to remove hot tar or asphalt - correct answer 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 - correct answer cortical and premotor cortex damage
what kind of brain injury would you expect if an adult client is positive for plantar infant
reflexes - correct answer upper motor neuron lesion
what kind of brain injury would you expect if an adult client is positive for rooting infant reflex -
correct answer frontal lobe damage
what kind of brain injury would you expect if an adult client is positive for sucking infant reflex -
correct answer 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 - correct answer diffuse cortical dysfunction
What is the consensus formula for burns - correct answer 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 -
correct answer Restlessness, anxiety, Hypothermia
how much fluid replacement are you going to give the first 8 hours - correct answer 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 - correct answer Urine output
Besides a hyperbaric chamber how would you admin o2 to a client with CO poisoning - correct
answer 100% O2 with a non-rebreather
How would you treat a circumferential trunk burn that is swelling and why? - correct answer
Eschartomies R/T constriction of the chest wall expansion
what are the classification of shock - correct answer Cardiogenic; hypovolemic, neurogenic, and
Disruptive
All shock is caused by - correct answer inadequate tissue perfusion
Patho of hypovolemic shock - correct answer Inadequate circulating blood volume S/A burns,
hemorrhage, dehydration
Patho for cardiogenic shock - correct answer Inadequate pumping action of the heart S/A MI,
CHF, PE
What are the 3 subclasses of Distributive shock - correct answer Anaphylactic; Septic;
Neurogenic
Patho for neurogenic shock - correct answer interference of the nervous system that controls
the blood vessels
Patho for septic shock - correct answer 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 -
correct answer 15-25%, or 1/3 of the body blood, or 5L
clients who experience slow blood loss can - correct answer Tolerate the blood loss better then
a client with rapid blood loss
Signs and symptoms of compensatory shock - correct answer hypotension, tachycardia,
tachypnea, hypothermia, decrease pulse pressure
During compensatory stage of shock, why would you hear hypoactive bowl sounds and cool and
clammy skin - correct answer 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 - correct answer High
production of aldosterone
why do RR increase in compensatory stage of shock - correct answer 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 -
correct answer Lactic acid, Compensatory
Why would you not give someone with impaired hepatic function lactated ringers - correct
answer 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 -
correct answer 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 - correct answer progressive
What happends to the body when build up of lactic acid occurs - correct answer increase
capillary permeability; relaxation of capillary spincter; blood is retaining in the cap beds
S&S of the progressive stage of shock - correct answer Hypoxia, alveolar collapse, pulmonary
edema, cardiac dysrhythmias, ischemic heart, ARF, DIC, Mental status change
Patho of the progressive stage of shock - correct answer organ suffering from hypoxia,
vasoconstriction decrease cell perfusion, GFR cannot be maintained
How do you calculate MAP - correct answer Systolic (2 X diastolic) / 3
Manis of shock - correct answer 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 - correct answer SIRS
S&S of Hypovolemic shock - correct answer 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)
Pt with a hernia repair comes back post op VS; 99/50 HR; 115 RR; 28, Pain 5 O2 89% - What
would you do first - correct answer 1) Treat O2 levels by Raising HOB and applying O2
2) Treat hypotension; Fluid replacement (LR)
3) manage pain
What will determine what you would do for your patient first - correct answer the results of
your head to toe assessment.
