Burn the House Down
As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient’s urine for:
A. Hemoglobin and myoglobin
B. Free iron and white blood cells
C. Protein and red blood cells
D. Potassium and Urea
A. Patients who’ve experienced a severe electrical burn or full-thickness burns are at risk for acute kidney injury. This is because the muscles can experience damage from the electrical current leading them to release myoglobin. In addition, the red blood cells will release hemoglobin. These substances will collect in the kidneys leading to acute tubular necrosis (hence leading to AKI). Therefore, the nurse should monitor the patient’s urine for these substances.
True or False: Septic shock causes system wide vasodilation which leads to an increase in systemic vascular resistance. In addition, septic shock causes increased capillary permeability and clot formation in the microcirculation throughout the body.
FALSE. This statement is incorrect because there is a DECREASE (not increased) systemic vascular resistance in septic shock due to vasodilation. In septic shock, vasodilation is system wide. In addition, septic shock causes increased capillary permeability and thrombi formation in the microcirculation throughout the body. The vasodilation, increased capillary permeability, and clot formation in the microcirculation all leads to a decrease in tissue perfusion. This causes organ and tissue dysfunction, hence septic shock.
A patient who is experiencing hypovolemic shock has decreased cardiac output, which contributes to ineffective tissue perfusion. The decrease in cardiac output occurs due to?
A. An increase in cardiac preload
B. An increase in stroke volume
C. A decrease in cardiac preload
D. A decrease in cardiac contractility
C. Because there is a major depletion of volume in the intravascular system, there will be a decrease in the amount of venous return to the heart (this is the amount of blood draining back to the heart). Hence, this will lead to a DECREASE in preload. Remember preload is the amount the ventricles stretch once their filled with blood. The ventricle won’t be stretching too much because there isn’t enough fluid to fill them. This will decrease stroke volume and in turn decrease cardiac output.
Which space within the meningeal layers contains cerebrospinal fluid (CSF)?
A. subdural space
B. epidural space
C. subarachnoid space
D. epiarachnoid space
C: subarachnoid space. The subarachnoid space, located between the arachnoid mater and pia mater, contains cerebrospinal fluid (CSF), which cushions and protects the brain and spinal cord. In contrast, the epidural and subdural spaces do not normally contain CSF.
The patient arrives back to the room following a lumbar puncture. Which action by the nurse is correct?
A. Assists the patient to the bathroom
B. Educates the patient to avoid caffeine for the next 48 hours
C. Keeps the patient in a flat position for 2 hours
D. Elevates the head of the bed to 30 degrees
C: Keeps the patient in a flat position for 2 hours. After a lumbar puncture, the patient should remain lying flat for 1–2 hours to reduce the risk of a post-procedure headache caused by cerebrospinal fluid leakage. Elevating the head of the bed too soon (even to 30°) can worsen headache symptoms. Assisting the patient to the bathroom immediately is not recommended (a bedpan should be used). Caffeine can actually help prevent a post-dural headache that can sometimes occur so the patient does not need to avoid it.
You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as:
A. 1st Degree (superficial)
B. 2nd Degree (partial-thickness)
C. 3rd Degree (full-thickness)
D. 4th Degree (deep full-thickness)
B. These are the classic characteristics of a 2nd degree (partial-thickness) burn.
A patient is at risk for septic shock when a microorganism invades the body. Which microorganism is the MOST common cause of sepsis?
A. Fungus
B. Virus
C. Parasite
D. Bacteria
D. Gram-positive or gram-negative bacteria are the MOST common cause of sepsis.
Select all the conditions below that increases a patient’s risk for absolute hypovolemic shock:
A. Burns
B. Vomiting
C. Long bone fracture
D. Surgery
E. Diarrhea
F. Sepsis
B, D, and E. Vomiting, diarrhea, and surgery can all increase the loss of fluid volume outside the body, which are absolute hypovolemic shock types. Burns, long bone fracture, and sepsis can lead to an inside fluid shift of fluid from the intravascular system and are relative hypovolemic shock types.
You are assessing a patient with suspected meningitis. When the patient is placed in the supine position with the hips and knees flexed at 90 degrees, extending the knee causes pain and resistance. This finding is documented as a positive __ sign.
A. Cullen’s
B. McBurney’s
C. Brudzinski’s
D. Kernig’s
D: Kernig’s sign. Kernig’s sign is a classic physical exam finding in meningitis. It is positive when pain or resistance occurs during passive extension of the knee while the hip is flexed at 90 degrees. This indicates irritation of the meninges. Brudzinski’s sign is another meningeal test, but it is positive when hip and knee flexion occur involuntarily in response to neck flexion. Cullen’s and McBurney’s signs are unrelated to meningitis; they indicate intra-abdominal pathology.
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?
A. Test the drainage for glucose
B. Suction the nostrils
C. Notify the physician
D. Ask the client to blow their nose
Test the drainage for glucose.
Answer Rationale:
This is the priority nursing action. Because of the high risk of cerebral spinal fluid (CSF) leak in clients with basal skull fractures, the nurse should realize there is a possibility that the clear fluid coming from the client's nostril is CSF, which will test positive for glucose.
A patient has experienced full-thickness burns to the face and neck. As the nurse it is priority to:
A. Prevent hypothermia
B. Assess the blood pressure
C. Assess the airway
D. Prevent infection
C. Due to the location of the burns (face and neck), the patient is at major risk for respiratory issues due to damage to the upper airways and the risk of an inhalation injury.
A patient with a fever is lethargic and has a blood pressure of 89/56. The patient’s white blood cell count is elevated. The physician suspects the patient is developing septic shock. What other findings indicate this patient is in the “early” or “compensated” stage of septic shock? Select all that apply:
A. Urinary output of 60 mL over 4 hours
B. Warm and flushed skin
C. Tachycardia
D. Bradypnea
B and C. In the early or compensated stage of septic shock, the patient is in a hyperdynamic state. This is different from the other types of shock like hypovolemic or cardiogenic (vasoconstriction is occurring in these types of shock). In septic shock, vasodilation is occurring and this leads to WARM and FLUSHED skin in the early stage. However, in the late stage the skin will be cool and clammy. Tachycardia and TACHYpnea (not bradypnea) occurs in the early stage too as a compensatory mechanism. Oliguria (option A) is in the late stage or uncompensated when the kidneys are starting to fail.
One of your patients begins to vomit large amounts of bright red blood. The patient is taking Warfarin. You call a rapid response. Which assessment findings indicate this patient is developing hypovolemic shock? Select all that apply:
A. Temperature 104.8 ‘F
B. Heart rate 40 bpm
C. Heart rate 140 bpm
D. Anxiety, restlessness
E. Urinary output 15 mL/hr
F. Blood pressure 70/56
G. Pale, cool skin
H. Weak peripheral pulses
I. Blood pressure 220/106
C, D, E, F, G, and H. Signs and symptoms of hypovolemic shock include: tachycardia, hypotension, increased respiratory rate, cool/pale/clammy skin, anxiety, decreased urinary output (normal UOP is >30 mL/hr), weak peripheral pulses
During the assessment of a patient with increased ICP, you note that the patient’s arms are extended straight out and toes pointed downward. You will document this as:
A. Decorticate posturing
B. Decerebrate posturing
C. Flaccid posturing
B
A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing?
A. Coughing
B. Sneezing
C. Talking
D. Valsalva maneuver
E. Vomiting
F. Keeping the head of the bed between 30- 35 degrees
The answers are A, B, D, and E. These activities can increase ICP.
A patient arrives to the ER due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury?
A. Carbonaceous sputum
B. Hair singeing on the head and nose
C. Lhermitte’s Sign
D. Bright red lips
E. Hoarse voice
F. Tachycardia
A, B, D, E, and F. These are all signs of a possible inhalation injury. Bright red lips and tachycardia are present in carbon monoxide poisoning as well.
Your patient is receiving aggressive treatment for septic shock. Which findings demonstrate treatment is NOT being successful? Select all that apply:
A. MAP (mean arterial pressure) 40 mmHg
B. Urinary output of 10 mL over 2 hours
C. Serum Lactate 15 mmol/L
D. Blood glucose 120 mg/dL
E. CVP (central venous pressure) less than 2 mmHg
A, B, C, and E. When answering this question, select the options that would indicate the body’s organs/tissues are NOT being perfused adequately. A MAP should be 65 or greater for proper tissue perfusion to occur. Urinary output should be at least 30 mL/hr. Serum lactate should be less than 2 mmoL/L….if it’s high this indicates cells are not receiving enough oxygen due to low tissue perfusion. A central venous pressure (CVP) should be greater than 2 mmHg. This shows the filling pressure in the right side of the heart. If this number is low there is not enough fluid filling in the heart to maintain cardiac output. This occurs in septic shock due to hypovolemia from increased capillary permeability where fluid shifted from the intravascular to the interstitial space.
Which patient below is at MOST risk for developing cardiogenic shock?
A. A 52-year-old male who is experiencing a severe allergic reaction from shellfish.
B. A 25-year-old female who has experienced an upper thoracic spinal cord injury.
C. A 72-year-old male who is post-op from a liver transplant.
D. A 49-year-old female who is experiencing an acute myocardial infarction.
D. An acute MI (heart attack) is the main cause of cardiogenic shock. It happens because a coronary artery has become blocked. Coronary arteries supply the heart muscle’s cells with oxygenated blood. If they don’t receive this oxygenated blood they will die, which causes the heart muscle to quit working (hence pumping efficiently). When the heart muscle fails to pump efficiently, cardiac output fails and cardiogenic shock occur.
Your patient, who has a spinal cord injury at T3, states they are experiencing a throbbing headache. What is your NEXT nursing action?
A. Perform a bladder scan
B. Perform a rectal digital examination
C. Assess the patient’s blood pressure
D. Administer a PRN medication to alleviate pain and provide a dark, calm environment.
C. This is the nurse’s NEXT action. The patient is at risk for developing autonomic dysreflexia because of their spinal cord injury at T3 (remember patients who have a SCI at T6 or higher are at MOST risk). If a patient with this type of injury states they have a headache, the nurse should NEXT assess the patient’s blood pressure. If it is elevated, the nurse would take measures to check the bladder (a bladder issue is the most common cause of AD), bowel, and skin for breakdown.
A patient is on IV Norepinephrine for treatment of septic shock. Which statement is FALSE about this medication?
A. “The nurse should titrate this medication to maintain a MAP of 65 mmHg or greater.”
B. “This medication causes vasodilation and decreases systemic vascular resistance.”
C. “It is used when fluid replacement is not unsuccessful.”
D. “It is considered a vasopressor.”
B. This statement is FALSE because this medication causes vasoconstriction (not vasodilation) which INCREASES systemic vascular resistance.
You’re providing education to a group of local firefighters about carbon monoxide poisoning. Which statement is correct about the pathophysiology regarding this condition?
A. “Patients are most likely to present with cyanosis around the lips and face.”
B. “In this condition, carbon monoxide binds to the hemoglobin of the red blood cell leading to a decrease in the ability of the hemoglobin to carry oxygen to the body.”
C. “Carbon monoxide poisoning leads to a hyperoxygenated state, which causes hypercapnia.”
D. “Carbon monoxide binds to the hemoglobin of the red blood cell and prevents the transport of carbon dioxide out of the blood, which leads to poisoning.”
B. This is the only correct statement about carbon monoxide poisoning.
A patient in septic shock receives large amounts of IV fluids. However, this was unsuccessful in maintaining tissue perfusion. As the nurse, you would anticipate the physician to order what NEXT?
A. IV corticosteroids
B. Colloids
C. Dobutamine
D. Norepinephrine
D. Fluids are ordered FIRST in septic shock. If this is unsuccessful, then vasopressors are ordered NEXT. Norepinephrine is used as a first-line agent. Dobutamine may sometimes be used but for its inotropic effects on the heart.
You’re providing care to a patient experiencing neurogenic shock due to an injury at T4. As the nurse, you know which of the following is a patient safety priority?
A. Keeping the head of the bed greater than 45 degrees at all times.
B. Repositioning the patient every thirty minutes.
C. Keeping the patient’s spine immobilized.
D. Avoiding log-rolling the patient during transport.
C. It is very important when a patient has a spinal cord injury to keep the spine protected. The nurse wants to prevent further damage or perfusion issues to the spinal cord. Therefore, the patient’s spine should be immobilized. Example: usage of cervical collar, log-rolling, usage of a backboard.
During nursing report you learn that the patient you will be caring for has Guillain-Barré Syndrome. As the nurse you know that this disease tends to present with:
A. signs and symptoms that are unilateral and descending that start in the lower extremities
B. signs and symptoms that are symmetrical and ascending that start in the upper extremities
C. signs and symptoms that are asymmetrical and ascending that start in the upper extremities
D. signs and symptoms that are symmetrical and ascending that start in the lower extremities
D. GBS signs and symptoms will most likely start in the lower extremities (ex: feet), be symmetrical, and will gradually spread upward (ascending) to the head. There are various forms of Guillain-Barré Syndrome. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) is the most common type in the U.S. and this is how this syndrome tends to present.
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
A. Hypotension
B. Anuria
C. Increased RR
D. Decreased LOC
C - Increased RR, When shock occurs, the body attempts to compensate for the decreased level of oxygenation and tissue perfusion. Initially, the client will display an increased respiratory rate as the body tries to increase oxygen delivery to the tissues. Additional compensatory manifestations of shock include increased heart rate, decreased urine output, and cold, clammy skin.