The leading cause of spinal cord injuries in older adults is?
What is falls.
The nurse is caring for a 65 yr old female with increased ICP who is on a 3% saline infusing. Upon the next reassessment the nurse finds the patient tachypnec with bilateral rales to the lower fields of the lungs upon ausculataion. The nurse understands that what complication has potentialy occured?
What is fluid overload due to 3% infusion for drawing fluid out of brain to relieve cerebral edema and increase Na level.
A patient with a sustained head injury has an ICP of 20. Name 1 expected nursing intervention for this patient.
What is keep HOB elevated at 30 degrees
Decrease stimuli
Cluster nursing care
Slow patient turning
Teach breathing techniques
A patient reports to the nurse chest pain, nausea, and dizziness. What priority diagnostic would you do next, provide your rationale.
What is a 12-lead EKG for rhythm interpretation d/t subjective reported symptoms to r/o lethal rhythms.
Cool, pale, shiny skin, diminished pulses, dependent rubor, pallor on elevation.
Name that era (aka condition)?
What is Peripheral Artery Disease
A patient is admitted to the Med-Surg unit for hypertensive crisis. Which assessment finding should be reported to the provider.
Heart Rate of 98
SpO2 94% on 2L NC
Blood Pressure 198/100
Lung Sounds diminished to the lower bases
Patient A/Ox3, decreased sensation to the left arm with drift
What is Patient A/Ox3, decreased sensation to the left arm with drift
A patient arrives after being ejected from an SUV. GCS 12, dilated pupils, abrasions noted to the head, neck trunk, bilateral arms. The patient is unable to report and is repeative with words. What is the priority action for this patient?
What is mobilize head and neck (c-spine).
The nurse understands that gathering what peice of information is highly crucial with acute stroke patients.
What is last known well (LKW).
What is the first step after intubation to verify ET tube placement?
What is auscultate bilateral breath sounds/equal rise/fall of chest for tube placement with attachment of CO2 monitor.
Warm skin, brown discoloration, edema, achy & heaviness. Name that disorder.
What is PVD
A patient presents with following rhythm
A/O x4, chest tightness, pressure, diaphoretic. Medications have been unsuccessful. Name that rhythm and what the next intervention would be.
What is PSVT and cardioversion with sedation (Versed) before procedure.
A patient with a C5 spinal cord injury should take what priority assessment?
What is respiratory assessment
A patient with CHF is reports they have been taking their medications as prescribed (beta-blocker, ACE-inhibitor, diuretic, and biguanide). Which assessment finding raises the greatest concern?
Dry, hacking cough
Edema to lower extremities
Blood Pressure 88/40
Heart Rate of 62 BPM
What is Blood Pressure 88/40
The nurse is caring for a patient present with sepsis. Explain with rationale the diagnostic work up for sepsis and treatment leading into septic shock.
What is rule out infection: blood cultures, trending lactic, administer broad spectrum anx till cultures come back and can be tailored to growth, CXR, urine culture, culture any drainage from patient, CRP, trend WBC, give 30mL/kg fluid bolus to support hemodynamic support and infection (dehydration) inflammatory response. If fluid bolus does not bring up BP then start Vasopressor (Levophed)
A nurse is documenting extension and adduction of arms, extension of legs and plantar flexion of the feet what reported pathophysiology is of the patient is potentially going on?
What is decerebrate posturing
The patient presetns with following rhythm
what rhythm is above and what treatment is recommended?
What is Ventricular Tachycardia. Check a pulse if pulseless start CPR, Epi, advanced airway, amniodarone, defibrilate.
What diagnostics in Sepsis should be completed within the First hour?
What is blood cultures, lactic acid, antibiotics, 30mL/kg fluid bolus
A patient presents with burns to the entire anterior face, anterior trunk, entire left leg, and the left right arm. Utilizing the rule of 9's, what is the TBSA?
What is 49.5%
The nurse understands that when setting up an arterial line it is important to ensure what components?
What is observe the waveform, ensure the flush system delivers 1-3 mL/kg, perform neurovascular checks on the patient.
Patient reports shortness of breath, chest pain with deep inspiration. Apical pulse regular with murmur. Respirations slightly labored with occasional nonproductive cough. Crackles auscultated throughout the lung fields. Flat, reddened macules noted on the palms of the hands bilaterally.
What is Endocarditis
A patient has a potassium level of 2.8 mEq/L. What is the priority nursing action?
What is place the patient on cardiac monitoring and monitor for lethal arrhythmias
A patient with following rhythm is at risk for developing what complication? Name the rhythm first! 
What is STEMI & at risk for Cardiogenic Shock.
Professor Lehman in her Senior year of high school was a super star exhibiting talent in what area of her high-school?
Semi state winner in Trombone playing
Hobby horse Semi-finalist
Gold trophy as Alto in show choir
Created a new breed of ducks in her families backyard pond and exhibited them at the science fair taking 7th place
What is Alto in show choir..with killer dance moves
The nurse is providing education regarding spinal cord injuries. What is the best way to prevent SCI?
What is identify high-risk persons and education preventative measures
High pitched, scratchy sound heard during S1 and/or S2 at the apex