SCI
A person with total loss below the level of injury has no sensation, motor reflex or activity. This is what type of condition?
Answer: Spinal shock
Rationale: 50% of people with spinal cord injury occur loss of sensation and motor reflexes and can be temporary.
If a patient presents with dehydration and severe diarrhea after one week Would it be a priority concern that the patient has new onset confusion or has a heart rate of 100.
Answer: New onset confusion would be the nurse concern
Rationale: With an indication of shock being severe or progressive mental status change would be the concern
Temperature criteria for SIRS includes this abnormal high or low range.
Answer: What is >38°C (100.4°F) or <36°C (96.8°F)?
Rationale: Temperature dysregulation reflects systemic inflammation.
What population is at the greatest risk for developing sepsis?
Answer: Infant and older adults
Rationale: Both groups have weaker or less efficient immune systems
Why is it important for nurses to develop strong clinical judgement?
Answer: It allows them to recognize changes in patient conditions, make safe and timely decisions, and prioritize interventions.
Signs and symptoms of a spinal cord injury patient that would alert the nurse toward autonomic dysreflexia?
Answer: Headache and rising blood pressure
Rationale: with autonomic dysreflexia there is widening blood pressures increasing up to 300 mm Hg systolic and a throbbing headache
How does epinephrine help a patient in respiratory distress after eating a food item they are allergic to?
Answer: Epinephrine causes vasoconstriction
Rationale: With the Vasoconstriction being created the bronchi are able to dilate and block histamines.
This white blood cell count abnormality is included in SIRS criteria. What are the ranges?
Answer: What is >12,000 or <4,000
Rationale: Indicates immune system activation or depletion.
What intervention is the most effective initial treatment for sepsis?
Answer: Fluid replacement
Rationale: Rapidly restores intravascular volume, improves tissue profusion and counteracts vasodilation.
Why is it important for nurses to provide individualized patient care?
Answer: It is important because each patient has unique needs. As nurses, we will be caring for patients in different age groups, socioeconomic status,ethnicities,and religious backgrounds.
What priority bodily function should a nurse monitor in a patient who has suffered a C5 injury after a cliff hiking accident?
Answer: respiratory function
Rationale: With decreased volume and expansion there will be labored ventilation and the nurse should prioritize possible ventilation therapy
Why would it be concerning for a patient who has septic shock to take furosemide?
Answer:this will decrease the patents perfusion
Rationale: This will further deplete the patient's urine output and filling pressures.
This coagulation disorder is commonly seen in MODS.
Answer: What is DIC (Disseminated Intravascular Coagulation)
Rationale: Widespread clotting and bleeding occur.
What are some manifestations of early (warm) septic shock?
Answer: Increased pulse/thready, warm/flushed skin, deep and rapid respirations, decreased CVP.
Rationale: Sepsis causes massive vasodilation and increased capillary permeability leading to these symptoms.
Why is educating patients a critical nursing responsibility?
Answer: It empowers clients to be more engaged, decreases complications, decreases readmissions, and helps clients learn self sufficiency
What are the primary functions of the spinal cord?
Answer: produces signals to the brain which coordinate reflexes and controls of movement.
Rationale: This is the main transmission for information between the brain and nervous system Which is crucial for coordination and sensory perception
What are the common signs and symptoms associated with shock?
Answer: low blood pressures, confusion, weakness,rapid heartbeat, cool/clammy skin.
Rationale: The earlier these signs can be recognized the better interventions can be imposed for your patient
A nurse is prioritizing care for clients. Which client should the nurse assess first?
A. Client with SIRS and temperature 38.2°C
B. Client with SIRS and heart rate 104/min
C. Client with SIRS and confusion with decreased urine output
D. Client with SIRS requesting pain medication
Answer: C
Rationale:
Confusion and decreased urine output indicate possible organ dysfunction and require
immediate assessment. Priority is based on ABCs and perfusion.
What condition may develop in a patient who uses tampons for a prolonged period of time and begins to show signs of sepsis?
Answer: Toxic shock syndrome
Rationale: Prolonged tampon use can allow bacteria to proliferate and release toxins.
What does collaboration require?
Answer: Two or more individuals working toward a common goal with skills, knowledge and resources. Use of SBAR to communicate clearly.
What is the difference between complete and incomplete spinal cord injury
Answer: A complete spinal cord injury would produce a total loss of motor and sensory below the level of injury while incomplete still would allow for some movement or function.
Answer: increased urine output
Rationale: An increase in urine output means there was a return to adequate renal perfusion.
This lab helps evaluate effectiveness of sepsis treatment over time.
Answer: What is lactate trending down?
Rationale: Decreasing lactate = improved perfusion.
What vaccination can older adults receive to help prevent infections that may lead to sepsis?
Answer: Pneumovax
Rationale: This vaccination protects against streptococcus pneumoniae, which can rapidly progress to sepsis.
What is a sentinel event?
Answer: Serious errors that result in harm or death to a patient.
Rationale: These events require immediate attention because they involve unexpected incidents that can result in serious harm.