ATI Flashcards
hypoxia, brain injury or death will occur within ___-__ min if the airway is not patent.
.
3 to 5
If a client is awake and responsive, the airway is____
open
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 _______
head-tilt/chin-lift
cervical spine injury
If the client is unresponsive with suspicion of trauma, the airway should be opened with a ________ maneuver
modified jaw thrust
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.
Shock
5 nursing interventions for shock
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.
Hypothermia can lead to what 3 things
eventual coma
hypoxemia
acidosis.
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 _____
hypothermia
Generally, ice, tourniquets, heparin, and corticosteroids are contraindicated in the first ___–__ hr after the bite.
6 to 8
Antivenom based on the type and severity of a snake bite is most effective if administered within __-__ hr.
4 to 12
Assess for tissue edema every___-____ min if bitten by a snake or spider.
15 to 30
for ingested poision, what 3 things can help
activated charcoal
gastric lavage
aspiration
administer _______ if seizures occur
diazepam
Avoid the use of ____ in clients who are receiving
epinephrine.
MAOIs
injuries result from open flames and explosions.
Dry heat
injuries result from contact with hot liquid or steam. Scald injuries are more common in older adults and younger children
Moist heat
burns occur when hot metal, tar, or grease contacts the skin.
Contact
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.
Chemical
burns result when clothes ignite from heat or flames that electrical sparks produce.
Thermal
result from contact with electrical current that travels through the air from one conductor to another.
Flash (arc
results when a person touches electrical wiring or equipment.
Conductive electrical
most often result from therapeutic treatment for cancer or from sunburn.
Radiation
_____ damage findings include singed nasal hair, eyebrows, and eyelashes; sooty sputum;
hoarseness; wheezing; edema of the nasal septum; and smoky smelling breath.
Inhalation
(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.
Carbon monoxide inhalation
upper airway edema becomes pronounced __-__ hr after the beginning of fluid resuscitation.
8 to 12
Incision through the eschar relieves pressure from the constricting force of fluid buildup under circumferential burns on the extremity or chest and improves circulation.
Escharotomy
Incision through eschar and fascia relieves tissue pressure when escharotomy alone does not.
Fasciotomy
is an inflammation of the meninges, which are the membranes that protect the brain and spinal cord.
Meningitis
Bacterial meningitis can occur from what 3 things
otitis media
pneumonia
sinusitis
3 subjective clinical manifestation of Meningitis
Excruciating, constant headache Nuchal rigidity (stiff neck) Photophobia (sensitivity to light)
7 objective data clinical manifestation of Meningitis
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
is the most definitive diagnostic procedure.
CSF analysis
CSF is collected during a ______ performed by the provider.
lumbar puncture
patient with Meningitis are on ______ precautions
droplet
5 for patients with Meningitis
droplet precaution seizure precautions decreased stimuli HOB 30 degrees monitor for increased ICP
Anticonvulsants given if ICP increased or client experiences a seizure
phenytoin
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 concussion, or mild traumatic brain injury,
occurs when the brain is bruised and the client has a period of unconsciousness associated with stupor and or confusion,
A contusion
is a widespread injury to the brain that results in coma and is seen in severe head trauma.
Diffuse axonal injury
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.
basilar skull fracture
glucose
is a late finding of increased ICP characterized by severe hypertension with a widening pulse pressure (systolic high — diastolic low) and bradycardia.
Cushing’s triad
8 clinical manifestations of increased ICP
Cheyne-Stokes respirations
Severe headache
vomiting
Deteriorating level of consciousness
Dilated or pinpoint nonreactive pupils
abnormal posturing (decerebrate, decorticate, flaccidity)
Cushing’s triad.
Seizures
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
increased ICP
Client may be placed in coma to decrease cellular metabolic demand until ICP can be decreased with what meds
barbiturates
penotobarbitol
is used prophylactically to prevent or treat seizures. It was the first medication used to suppress seizure that did not depress the entire CNS.
Phenytoin
Medications such as mannitol and dexamethasone can be administered every_ hr for 24 to 72 hr postoperatively.
6 hrs
_______ is the downward shift of brain tissue due to cerebral edema.
A brain herniation
Findings include fixed dilated pupils, deteriorating level of consciousness, Cheyne- Stokes respirations, hemodynamic instability, and abnormal posturing.
A brain herniation
Intracranial hemorrhage is treated with________
osmotic diuretics.
involve a disruption in the cerebral blood flow secondary to ischemia, hemorrhage, brain attack, or
embolism.
Strokes
type of stroke that occur secondary to a ruptured artery or aneurysm.
Hemorrhagic
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).
3 to 4.5 hours
Cerebral aneurysm Arteriovenous malformation (AV) Diabetes mellitus Obesity Hypertension Atherosclerosis Hyperlipidemia Hypercoagulability Atrial fibrillation Use of oral contraceptives smoking
are all risk factors for
stroke
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.
180
110
inability to speak
Expressive aphasia
inability to understand language
receptive aphasia
unable to recognize familiar objects
Agnosia
reading difficulty
Alexia
writing difficulty
Agraphia
right sided paralysis
hemiplegia
right sided weakness
hemiparesis
loss of visual field in one or both eyes
hemianopsia
8 clinical manifestations of left sided stroke
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
6 clinical manifestations of right sided stroke
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
Injuries in the cervical region result in _______ paralysis/paresis of all four extremities and trunk
quadriplegia:
Injuries below Tl result in_______: paralysis/paresis of the lower extremities.
paraplegia
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
Neurogenic shock
