ATI

Question 1

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

Answer 1

3 to 5

Question 2

If a client is awake and responsive, the airway is____

Answer 2

open

Question 3

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 _______

Answer 3

head-tilt/chin-lift

cervical spine injury

Question 4

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

Answer 4

modified jaw thrust

Question 5

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.

Answer 5

Shock

Question 6

5 nursing interventions for shock

Answer 6

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.

Question 7

Hypothermia can lead to what 3 things

Answer 7

eventual coma
hypoxemia
acidosis.

Question 8

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 _____

Answer 8

hypothermia

Question 9

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

Answer 9

6 to 8

Question 10

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

Answer 10

4 to 12

Question 11

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

Answer 11

15 to 30

Question 12

for ingested poision, what 3 things can help

Answer 12

activated charcoal
gastric lavage
aspiration

Question 13

administer _______ if seizures occur

Answer 13

diazepam

Question 14

Avoid the use of ____ in clients who are receiving

epinephrine.

Answer 14

MAOIs

Question 15

injuries result from open flames and explosions.

Answer 15

Dry heat

Question 16

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

Answer 16

Moist heat

Question 17

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

Answer 17

Contact

Question 18

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.

Answer 18

Chemical

Question 19

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

Answer 19

Thermal

Question 20

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

Answer 20

Flash (arc

Question 21

results when a person touches electrical wiring or equipment.

Answer 21

Conductive electrical

Question 22

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

Answer 22

Radiation

Question 23

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

Answer 23

Inhalation

Question 24

(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.

Answer 24

Carbon monoxide inhalation

Question 25

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

Answer 25

8 to 12

Question 26

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

Answer 26

Escharotomy

Question 27

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

Answer 27

Fasciotomy

Question 28

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

Answer 28

Meningitis

Question 29

Bacterial meningitis can occur from what 3 things

Answer 29

otitis media pneumonia sinusitis

Question 30

3 subjective clinical manifestation of Meningitis

Answer 30

``` Excruciating, constant headache Nuchal rigidity (stiff neck) Photophobia (sensitivity to light) ```

Question 31

7 objective data clinical manifestation of Meningitis

Answer 31

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

Question 32

is the most definitive diagnostic procedure.

Answer 32

CSF analysis

Question 33

CSF is collected during a ______ performed by the provider.

Answer 33

lumbar puncture

Question 34

patient with Meningitis are on ______ precautions

Answer 34

droplet

Question 35

5 for patients with Meningitis

Answer 35

``` droplet precaution seizure precautions decreased stimuli HOB 30 degrees monitor for increased ICP ```

Question 36

Anticonvulsants given if ICP increased or client experiences a seizure

Answer 36

phenytoin

Question 37

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.

Answer 37

A concussion, or mild traumatic brain injury,

Question 38

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

Answer 38

A contusion

Question 39

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

Answer 39

Diffuse axonal injury

Question 40

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.

Answer 40

basilar skull fracture glucose

Question 41

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

Answer 41

Cushing's triad

Question 42

8 clinical manifestations of increased ICP

Answer 42

Cheyne-Stokes respirations Severe headache vomiting Deteriorating level of consciousness Dilated or pinpoint nonreactive pupils abnormal posturing (decerebrate, decorticate, flaccidity) Cushing's triad. Seizures

Question 43

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

Answer 43

increased ICP

Question 44

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

Answer 44

barbiturates penotobarbitol

Question 45

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

Answer 45

Phenytoin

Question 46

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

Answer 46

6 hrs

Question 47

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

Answer 47

A brain herniation

Question 48

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

Answer 48

A brain herniation

Question 49

Intracranial hemorrhage is treated with________

Answer 49

osmotic diuretics.

Question 50

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

Answer 50

Strokes

Question 51

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

Answer 51

Hemorrhagic

Question 52

``` 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). ```

Answer 52

3 to 4.5 hours

Question 53

``` Cerebral aneurysm Arteriovenous malformation (AV) Diabetes mellitus Obesity Hypertension Atherosclerosis Hyperlipidemia Hypercoagulability Atrial fibrillation Use of oral contraceptives smoking ``` are all risk factors for

Answer 53

stroke

Question 54

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.

Answer 54

180 110

Question 55

inability to speak

Answer 55

Expressive aphasia

Question 56

inability to understand language

Answer 56

receptive aphasia

Question 57

unable to recognize familiar objects

Answer 57

Agnosia

Question 58

reading difficulty

Answer 58

Alexia

Question 59

writing difficulty

Answer 59

Agraphia

Question 60

right sided paralysis

Answer 60

hemiplegia

Question 61

right sided weakness

Answer 61

hemiparesis

Question 62

loss of visual field in one or both eyes

Answer 62

hemianopsia

Question 63

8 clinical manifestations of left sided stroke

Answer 63

``` 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 ```

Question 64

6 clinical manifestations of right sided stroke

Answer 64

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

Question 65

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

Answer 65

quadriplegia:

Question 66

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

Answer 66

paraplegia

Question 67

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

Answer 67

Neurogenic shock