MED/SURG: TRAUMA: AAREVIEW

Question 1

Delirium tremens

Delirium tremens

Answer 1

Delirium tremens is a severe form of alcohol withdrawal that involves sudden and severe mental or nervous system changes.

Symptoms most often occur within 48-96 hours after the last drink. However, they may occur up to 7 - 10 days after the last drink.

Question 2

Q: A prisoner, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis?

1. Risk for Injury related to seizures
2. Risk for Other-Directed Violence related to hallucinations
3. Risk for Situational Low Self-esteem related to police custody
4. Risk for Nutritional Deficit related to chronic alcohol abuse

Answer 2

#1

The patient demonstrates neurologic hyperactivity and is on the verge of a seizure. Patient safety is the priority. The patient needs chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) will also be ordered to address the other problems. The other diagnoses are pertinent but not as immediate.

Question 3

Following emergency endotracheal intubation, you must verify tube placement and secure the tube. List in order the steps that are required to perform this function?

a. Obtain an order for a chest x-ray to document tube placement.
b. Secure the tube in place.
c. Auscultate the chest during assisted ventilation.
d. Confirm that the breath sounds are equal and bilateral.

Answer 3

CDBA

Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the mid-epigastric area, tube placement must be corrected immediately. Securing the tube is appropriate while waiting for the x-ray study.

Question 4

WERNICKE’S SYNDROME

An intoxicated patient presents with slurred speech, mild confusion, and uncooperative behavior. The patient is a poor historian but admits to “drinking a few on the weekend.” What is the priority nursing action for this patient?

1. Obtain an order for a blood alcohol level.
2. Contact the family to obtain additional history and baseline information.
3. Administer naloxone (Narcan) 2 – 4 mg as ordered.
4. Administer IV fluid support with supplemental thiamine as ordered.

Answer 4

Administer IV fluid support with supplemental thiamine as ordered.

The patient presents with symptoms of alcohol abuse and there is a risk for Wernicke’s syndrome, which is caused by a thiamine deficiency. Multiples drug abuse is not uncommon; however, there is nothing in the question that suggests an opiate overdose that requires naloxone. Additional information or the results of the blood alcohol level are part of the total treatment plan but should not delay the immediate treatment.

Question 5

WERNICKE-KORSAKOFF SYNDROME

MedlinePlus

Answer 5

Wernicke-Korsakoff syndrome is a brain disorder due to thiamine (vitamin B1) deficiency.

Wernicke encephalopathy and Korsakoff syndrome are different conditions. Both are due to brain damage caused by a lack of vitamin B1.

Lack of vitamin B1 is common in people with alcoholism. It is also common in persons whose bodies do not absorb food properly (malabsorption), as sometimes occurs with a chronic illness or after obesity (bariatric) surgery.

Korsakoff syndrome, or Korsakoff psychosis, tends to develop as Wernicke symptoms go away. Wernicke encephalopathy causes brain damage in lower parts of the brain called the thalamus and hypothalamus. Korsakoff psychosis results from permanent damage to areas of the brain involved with memory.

Question 6

B1 Vitamin Food Source

B1 Vitamin Food Source (3)

Answer 6

1. Fish
2. Pork
3. Nuts

Question 7

A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus?

1. PO phenytoin and carbamazepine
2. IV lorazepam (Ativan)
3. IV carbamazepine
4. IV magnesium sulfate

Answer 7

IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Tegretol is used in the management of generalized tonic-clonic, absence or mixed type seizures, but it does not come in an IV form. PO (per os) medications are inappropriate for this emergency situation. Magnesium sulfate is given to control seizures in toxemia of pregnancy.

Question 8

A tearful parent brings a child to the ED for taking an unknown amount of children’s chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be immediately reported to the physician?

1. The ingested children’s chewable vitamins contain iron.
2. The child has been treated several times for ingestion of toxic substances.
3. The child has been treated several times for accidental injuries.
4. The child was nauseated and vomited once at home

Answer 8

Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and hepatic failure. Deferoxamine is an antidote that can be used for severe cases of iron poisoning. Other information needs additional investigation, but will not change the immediate diagnostic testing or treatment plan.

Question 9

An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse’s first week on the job. Which area of the ED is the most appropriate assignment for the nurse?

1. Trauma team
2. Triage
3. Ambulatory or fast track clinic
4. Pediatric medicine team

Answer 9

The fast track clinic will deal with relatively stable patients. Triage, trauma, and pediatric medicine should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment.

Question 10

You are assigned to telephone triage. A patient who was stung by a common honey bee calls for advice, reports pain and localized swelling, but denies any respiratory distress or other systemic signs of anaphylaxis. What is the action that you should direct the caller to perform?

1. Call 911.
2. Remove the stinger by scraping.
3. Apply a cool compress.
4. Take an oral antihistamine.

Answer 10

The stinger will continue to release venom into the skin, so prompt removal of the stinger is advised. Cool compresses and antihistamines can follow. The caller should be further advised about symptoms that require 911 assistance.