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critical care > ATI > Flashcards

ATI Flashcards

1
Q

hypoxia, brain injury or death will occur within ___-__ min if the airway is not patent.
.

A

3 to 5

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2
Q

If a client is awake and responsive, the airway is____

A

open

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3
Q

If the client is unresponsive without suspicion of trauma, the airway should be opened with a_______ maneuver.

Do NOT perform this technique on clients who have a potential _______

A

head-tilt/chin-lift

cervical spine injury

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4
Q

If the client is unresponsive with suspicion of trauma, the airway should be opened with a ________ maneuver

A

modified jaw thrust

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5
Q

is the body’s response to inadequate tissue perfusion and oxygenation. It manifests with an increased heart
rate and hypotension and can result in tissue ischemia and necrosis.

A

Shock

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6
Q

5 nursing interventions for shock

A

Administer oxygen.

Apply pressure to obvious bleeding.

Elevate lower extremities to shunt blood to vital organs.

Administer IV fluids and blood products.

Monitor vital signs.

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7
Q

Hypothermia can lead to what 3 things

A

eventual coma
hypoxemia
acidosis.

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8
Q 
Remove wet clothing from the client. 
Cover the client with warm blankets. 
Increase the temperature of the room. 
Use a heat lamp to provide additional warmth. 
Infuse warmed IV fluids.

are all interverntions for _____

A

hypothermia

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9
Q

Generally, ice, tourniquets, heparin, and corticosteroids are contraindicated in the first ___–__ hr after the bite.

A

6 to 8

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10
Q

Antivenom based on the type and severity of a snake bite is most effective if administered within __-__ hr.

A

4 to 12

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11
Q

Assess for tissue edema every___-____ min if bitten by a snake or spider.

A

15 to 30

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12
Q

for ingested poision, what 3 things can help

A

activated charcoal
gastric lavage
aspiration

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13
Q

administer _______ if seizures occur

A

diazepam

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14
Q

Avoid the use of ____ in clients who are receiving

epinephrine.

A

MAOIs

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15
Q

injuries result from open flames and explosions.

A

Dry heat

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16
Q

injuries result from contact with hot liquid or steam. Scald injuries are more common in older adults and younger children

A

Moist heat

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17
Q

burns occur when hot metal, tar, or grease contacts the skin.

A

Contact

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18
Q

result from exposure to a caustic agent. Cleaning agents in the home (drain cleaner, oven cleaner, bleach) and agents in the industrial setting (caustic soda, sulfuric acid) can cause chemical burns.

A

Chemical

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19
Q

burns result when clothes ignite from heat or flames that electrical sparks produce.

A

Thermal

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20
Q

result from contact with electrical current that travels through the air from one conductor to another.

A

Flash (arc

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21
Q

results when a person touches electrical wiring or equipment.

A

Conductive electrical

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22
Q

most often result from therapeutic treatment for cancer or from sunburn.

A

Radiation

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23
Q

_____ damage findings include singed nasal hair, eyebrows, and eyelashes; sooty sputum;
hoarseness; wheezing; edema of the nasal septum; and smoky smelling breath.

A

Inhalation

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24
Q

(from burns in an enclosed area) findings include headache, weakness, dizziness, confusion, erythema (pink or cherry red skin) and upper airway edema,
followed by sloughing of the respiratory tract mucosa.

A

Carbon monoxide inhalation

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25
Q

upper airway edema becomes pronounced __-__ hr after the beginning of fluid resuscitation.

A

8 to 12

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26
Q

Incision through the eschar relieves pressure from the constricting force of fluid buildup under circumferential burns on the extremity or chest and improves circulation.

A

Escharotomy

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27
Q

Incision through eschar and fascia relieves tissue pressure when escharotomy alone does not.

A

Fasciotomy

28
Q

is an inflammation of the meninges, which are the membranes that protect the brain and spinal cord.

A

Meningitis

29
Q

Bacterial meningitis can occur from what 3 things

A

otitis media
pneumonia
sinusitis

30
Q

3 subjective clinical manifestation of Meningitis

A 
Excruciating, constant headache 
Nuchal rigidity (stiff neck) 
Photophobia (sensitivity to light)
31
Q

7 objective data clinical manifestation of Meningitis

A

Fever and chills

Nausea and vomiting

Altered level of consciousness (confusion, disorientation, lethargy, difficulty arousing, coma)

Positive Kernig’s sign (resistance and pain with extension of the client’s leg from a flexed
position)

positive brudzinkis

hyperactive deep tendon reflex

seizure

32
Q

is the most definitive diagnostic procedure.

A

CSF analysis

33
Q

CSF is collected during a ______ performed by the provider.

A

lumbar puncture

34
Q

patient with Meningitis are on ______ precautions

A

droplet

35
Q

5 for patients with Meningitis

A 
droplet precaution
seizure precautions 
decreased stimuli 
HOB 30 degrees 
monitor for increased ICP
36
Q

Anticonvulsants given if ICP increased or client experiences a seizure

A

phenytoin

37
Q

occurs after head trauma that result in a change in the client’s neurological function but no identified brain damage and usually resolves within 72 hr.

A

A concussion, or mild traumatic brain injury,

38
Q

occurs when the brain is bruised and the client has a period of unconsciousness associated with stupor and or confusion,

A

A contusion

39
Q

is a widespread injury to the brain that results in coma and is seen in severe head trauma.

A

Diffuse axonal injury

40
Q

CSF leakage from the nose and ears can indicate a ________.

Test for the presence of ______ by assessing for the presence of a “halo sign” indicated by a clear or yellow-tinted ring surrounding a drop of blood when drainage is placed on a piece of gauze.

A

basilar skull fracture

glucose

41
Q

is a late finding of increased ICP characterized by severe hypertension with a widening pulse pressure (systolic high — diastolic low) and bradycardia.

A

Cushing’s triad

42
Q

8 clinical manifestations of increased ICP

A

Cheyne-Stokes respirations

Severe headache

vomiting

Deteriorating level of consciousness

Dilated or pinpoint nonreactive pupils

abnormal posturing (decerebrate, decorticate, flaccidity)

Cushing’s triad.

Seizures

43
Q

Hypercarbia, which leads to cerebral vasodilation

Endotracheal or oral tracheal suctioning

Coughing

Extreme neck or hip flexion/extension

Maintaining the head of the bed at an angle less than 30 degree

Increasing intra-abdominal pressure (restrictive clothing, Valsalva maneuver)

all causes of

A

increased ICP

44
Q

Client may be placed in coma to decrease cellular metabolic demand until ICP can be decreased with what meds

A

barbiturates

penotobarbitol

45
Q

is used prophylactically to prevent or treat seizures. It was the first medication used to suppress seizure that did not depress the entire CNS.

A

Phenytoin

46
Q

Medications such as mannitol and dexamethasone can be administered every_ hr for 24 to 72 hr postoperatively.

A

6 hrs

47
Q

_______ is the downward shift of brain tissue due to cerebral edema.

A

A brain herniation

48
Q

Findings include fixed dilated pupils, deteriorating level of consciousness, Cheyne- Stokes respirations, hemodynamic instability, and abnormal posturing.

A

A brain herniation

49
Q

Intracranial hemorrhage is treated with________

A

osmotic diuretics.

50
Q

involve a disruption in the cerebral blood flow secondary to ischemia, hemorrhage, brain attack, or
embolism.

A

Strokes

51
Q

type of stroke that occur secondary to a ruptured artery or aneurysm.

A

Hemorrhagic

52
Q 
Ischemic strokes (thrombotic or embolic) can be reversed with fibrinolytic therapy using alteplase, also known as tissue plasminogen activator (tPA), if given within\_\_-\_\_ hr of the initial symptoms (unless contraindicated by factors such as presence of active 
bleeding).
A

3 to 4.5 hours

53
Q 
Cerebral aneurysm 
Arteriovenous malformation (AV) 
Diabetes mellitus 
Obesity 
Hypertension 
Atherosclerosis 
Hyperlipidemia 
Hypercoagulability 
Atrial fibrillation 
Use of oral contraceptives 
smoking

are all risk factors for

A

stroke

54
Q

Notify the provider immediately if blood pressure
exceeds a systolic greater than ___ mm Hg or a diastolic greater than ____ mm Hg.

This can indicate the client is experiencing an ischemic stroke.

A

180

110

55
Q

inability to speak

A

Expressive aphasia

56
Q

inability to understand language

A

receptive aphasia

57
Q

unable to recognize familiar objects

A

Agnosia

58
Q

reading difficulty

A

Alexia

59
Q

writing difficulty

A

Agraphia

60
Q

right sided paralysis

A

hemiplegia

61
Q

right sided weakness

A

hemiparesis

62
Q

loss of visual field in one or both eyes

A

hemianopsia

63
Q

8 clinical manifestations of left sided stroke

A 
Expressive and receptive aphasia 
Agnosia
Alexia
Agraphia
Right extremity hemiplegia or hemiparesis  
Slow, cautious behavior 
Depression, anger, and quick to become frustrated 
Visual changes, such as hemianopsia
64
Q

6 clinical manifestations of right sided stroke

A

Altered perception of deficits

Unilateral neglect syndrome

Loss of depth perception

Poor impulse control and judgment

Left hemiplegia or hemiparesis

Visual changes, such as hemianopsia

65
Q

Injuries in the cervical region result in _______ paralysis/paresis of all four extremities and trunk

A

quadriplegia:

66
Q

Injuries below Tl result in_______: paralysis/paresis of the lower extremities.

A

paraplegia

67
Q

which is a complication of spinal trauma, causes a sudden loss of communication within the sympathetic nervous system that maintains the normal muscle tone in blood vessel walls

A

Neurogenic shock

critical care (6 decks)

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