Tissue Integrity
The _____________ layer of the skin helps regulate our body temperature.
Hypodermis
What is your primary assessment in a trauma?
Name 3 personality disorders from Cluster A:
What is it called if there is a cervical spinal cord injury and a patient has limited to no movement in their extremities?
Tetra/quadriplegic
Which patient below is at MOST risk for increased intracranial pressure?
A patient has experienced full thickness burns to the face and neck. As the nurse it is priority to:
Assess the airway
Name the three levels of Triage and in what time frame they need to be seen:
Emergent (life threatening)- seen immediately
Urgent (serious health problem)- seen within 1 hour
Non urgent (episodic illness) – seen within 24 hours
When caring for a client with a diagnosis of schizotypal personality disorder, the nurse should:
From top to bottom what are the levels of the spinal cord:
Cervical- thoracic- lumbar- sacral
What are the three signs of Cushing’s triad? And what does this indicate?
Increased systolic BP- decreased pulse- decreased respirations indicates an increase in intracranial pressure.
Select the patient below who is at MOST risk for complications following a burn:
A patient is in the acute phase of burn management. The patient experienced full-thickness burns to the perineum and sacral area of the body. In the patient’s plan of care, which nursing diagnosis is priority at this time?
Risk for infection
A client with antisocial personality is trying to convince a nurse that he deserves special privileges and that an exception to the rules should be made for him. Which of the following responses is the most appropriate?
“What you’re asking me to do is unacceptable.”
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 patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication?*
C. Restlessness
A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply:
Situation
Hypovolemic
A client with a diagnosis of narcissistic personality disorder has been given a day pass from the psychiatric hospital. The client is due to return at 6pm. At 5pm the client telephones the nurse in charge of the unit and says “6 o’clock is too early. I feel like coming back at 7:30.” The nurse would be most therapeutic by telling the client to:
. A 42-year-old male patient is admitted with a spinal cord injury. The patient is experiencing severe hypotension and bradycardia. The patient is diagnosed with neurogenic shock. Why is hypotension occurring in this patient with neurogenic shock?*
The patient’s autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring.
A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing?
A. Coughing
B. Sneezing
D. Valsalva maneuver
E. Vomiting
A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
63%
A client suffered an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to an LPN/LVN?
Which of the following statements is typical for a client diagnosed with a personality disorder?
In neurogenic shock, a patient will experience a decrease in tissue perfusion. This deprives the cells of oxygen that make up the tissues and organs. Select all the mechanisms, in regards to pathophysiology, of why this is occurring:*
A. Loss of vasomotor tone
C. Decrease in cardiac preload
E. Decrease in venous blood return to the heart
F. Venous blood pooling in the extremities
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: