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RNSG 2539 EXAM 3 2023 2024 | 100+
QUESTIONS AND VERIFIED
ANSWERS | LATEST UPDATE
Radiation side effects may include: -----CORRECT ANSWER------------ Fatigue
- Alopecia
- Sores in the mouth Clinical manifestations of basal cell carcinoma -----CORRECT ANSWER-----------small, waxy nodule with rolled, translucent, pearly borders clinical manifestations of squamous cell carcinoma -----CORRECT ANSWER------------ poorly defined margins
- ulcer
- flat red area
- cutaneous horn
- nodule
- red to flesh colored
- metastasis risk factors for leukemia -----CORRECT ANSWER-----------exposure to radiation previous tx with cancer drugs some antibiotics exposure to chemicals exposure to viruses inherited genetic disorders like Down Syndrome smoking clinical manifestations of lymphoma -----CORRECT ANSWER------------enlarged, painless lymph nodes
- night sweats, fever, weight loss
clinical manifestations of leukemia -----CORRECT ANSWER-----------1. anemia with fatigue, dyspnea and pallor
- Frequent infections and flu-like symptoms
- Enlarged lymph nodes and spleen
- Bleeding, bruising and petechiae
- Bone and joint pain post-op treatment for lung cancer -----CORRECT ANSWER-----------monitors the patient for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunction. The nurse also provides for the patient's comfort. thermal burns -----CORRECT ANSWER-----------caused by contact with open flames, hot liquids or surfaces, or other sources of high heat Treat by removing victim from source, cool burn with water, check for bleeding and shock, seek medical attention chemical burns -----CORRECT ANSWER-----------caused by contact with chemicals that can burn the skin Treat by flushing burn with lots of cool water to remove chemical, or brush powdered chemical off skin with clean cloth radiation burns -----CORRECT ANSWER-----------redness and blistering on the surface of the skin or other organs caused by intense exposure to ionising radiation Electrical Burns -----CORRECT ANSWER-----------frequently associated with significantly greater internal injuries than would be suspected from the appearance of entrance and exit wounds. May cause arrest through ventricular fibrillation activity
flexion-rotation spinal cord injury -----CORRECT ANSWER-----------displacement of vertebrae think of a fall, or violent collision. Ex. Christopher Reeve injury to cervical spine causes -----CORRECT ANSWER-----------injury to C4 causes tetraplegia from neck down injury to c6 causes tetraplegia from shoulders down injury to thoracic spine -----CORRECT ANSWER-----------Paralysis in legs and thoracic region but arms can still function Loss of bowel and bladder control Pain injury to lumbar spine -----CORRECT ANSWER-----------paralysis of legs and pelvic region Loss of bowel and bladder control Pain Sensory changes Spasticity and weakness medical interventions for spinal injury's -----CORRECT ANSWER-----------c-spine immobilization •The patient is kept on the transfer board. •No part of the body should be twisted or turned, and the patient is not allowed to sit up. •If cervical fracture is found the patient may be placed on a rotating specialty bed with cervical traction •Or in a cervical collar with a hard bed •Or a halo vest nursing interventions for spinal cord injury -----CORRECT ANSWER------------ immobilization
- assess resp dysfunction
- assess cardio fxn
- monitor s/s of hypovolemic shock
- assess nutritional status and presence of stress ulcers
- assess urinary and bowel fxn
- assess environment for temp control
- assess pain
- SCD, TED
- medications surgery options for spinal cord injury -----CORRECT ANSWER-----------Surgery is indicated if: •Compression of the cord is evident. •Fragmented or unstable vertebral body. •A wound that penetrates the cord. •Neurologic status is deteriorating. •Early stabilization improves outcome •Goal: stabilize & remove pressure to preserve function Medication •High-dose IV corticosteroids (methylprednisolone) spinal shock s/s -----CORRECT ANSWER-----------decreased reflexes, loss of sensation, and flaccid paralysis below the level of injury nursing diagnosis for high cervical spinal cord injury if pt is intubated -----CORRECT ANSWER-----------risk for injury what can be done to combat venous pooling and low bp in a patient with spinal cord injury -----CORRECT ANSWER-----------tilt gunnery or wheelchair What is neurogenic bladder -----CORRECT ANSWER------------Lack of nerve supply to the bladder
- Person can't feel when bladder is full
- Must use catheter to void clinical manifestations of neurogenic bladder -----CORRECT ANSWER------------ poor voiding due to inability to feel need to void
- overflow incontinence so full bladder cannot feel, incontinent
}Patients may or may not experience retrograde amnesia (inability to recall events just preceding injury) classic concussion -----CORRECT ANSWER-----------}Involves a temporary loss of consciousness ◦Usually less than five minutes ◦No longer than six hours ◦Retrograde or posttraumatic amnesia always present ◦May have headaches, dizziness, vertigo, nausea, visual disturbances, difficulty in concentration, poor memory, behavior disorders, irritability, anxiety, or insomnia Primary brain injury -----CORRECT ANSWER-----------}Occurs immediately on impact of mechanical force ◦Damage is done and cannot be reversed ◦Injury to brain or vasculature Secondary brain injury -----CORRECT ANSWER-----------}evolves over next hours or days ◦Results from inadequate nutrients and oxygen (perfusion) to brain cells ◦Death occurs at three points in time: ◦immediately after injury ◦Within 2 hrs of injury 3 weeks after injury post concussion syndrome -----CORRECT ANSWER-----------}Disabling difficulties may become evident after return to job or school }May benefit from referral to specialist }Must be advised to avoid activities with potential for high risk for repeated concussion, such as contact sports ◦Repeat concussion may cause autoregulatory dysfunction and progressive cerebral edema diffuse axonal injury -----CORRECT ANSWER-----------involves stretching, shearing, or tearing of the extension of the neuron that conducts electrical impulses away from the cell body. }Immediate and prolonged coma longer than six hours to persistent vegetative state
}May display decorticate or decerebrate posturing focal brain injury -----CORRECT ANSWER-----------}Contusion ◦Constitute most common types of brain injury ◦Bruising of brain tissue with associated hemorrhage and edema formation ◦May occur beneath an area of skull deformation ◦May occur secondary to acceleration-deceleration ◦May be due to rotation or penetrating mechanisms epidural hematoma -----CORRECT ANSWER-----------}Collection of blood between skull and dura mater ◦Usually arterial from tearing of middle meningeal artery ◦classic signs are unconsciousness-> lucid period - > decrease in LOC subdural hematoma -----CORRECT ANSWER-----------}Collection of blood in below dura ◦Usually venous bleeding maybe slower to develop intracerebral hematoma -----CORRECT ANSWER-----------}Hemorrhage into brain tissue ◦Creates a mass lesion- usually in frontal and temporal lobes ◦Size and location of hematoma determine patient outcome. primary treatment measures for TBI -----CORRECT ANSWER-----------oxygenation ventilation perfusion }Monitor for signs of increased ICP/Cerebral edema and treat Assessment for TBI -----CORRECT ANSWER-----------}Be alert for following signs: ◦Altered level of consciousness (LOC) ◦Confusion ◦Pupillary abnormalities ◦Altered or absent gag reflex ◦Sudden onset of neurological deficits ◦Changes in vital signs ◦Vision or hearing impairment
physical manifestations of encephalopathy -----CORRECT ANSWER-----------Breath with musty or sweet odor Sleep pattern disturbances Shaking hands Slurred speech, sluggish movements With Infection Fever, headache, nausea, seizures, abnormal cerebrospinal fluid Nursing interventions for encephalopathy -----CORRECT ANSWER-----------Patient education to include: no alcohol consumption, healthy diet and exercise, protected sexual intercourse, safety measures to prevent trauma, and avoiding exposure to infections. What is brain death? -----CORRECT ANSWER------------ An irreversible loss of all brain functions, including the brain stem
- Heart continues to beat and person is maintained on mechanical ventilation in the ICU
- Cerebral cortex stops functioning or is irreversibly damaged how do you confirm brain death -----CORRECT ANSWER----------- ¨Electroencephalogram (EEG) ¨Cerebral cerebral blood flow (CBF) study ¨A negative CBF study is indisputable evidence of brain death can a family member overturn a patients desire to be an organ donor upon death ----- CORRECT ANSWER-----------yes How do you keep organs viable in brain dead patient -----CORRECT ANSWER----------- Maintain airway Maintain normal temperature Maintain adequate hydration Prevent infection
what is the rule of 100's in brain dead patient to maintain organs -----CORRECT ANSWER-----------¨Maintain PaO2 at 100 mm Hg ¨Maintain urine output about 100 ml per hour ¤Less than 200 ml ¨Maintain systolic blood pressure of 110 mm Hg ¨Maintain temperature at about 100 degrees- (96 to 101) which organs can be donated from a cadaver -----CORRECT ANSWER----------- Corneas Heart / heart valves Lungs Liver Kidneys Stomach Small intestines Pancrease Uterus Tendons Ligament Bone Bone marrow Veins Skin Which organs can be donated by a living donor -----CORRECT ANSWER-----------Liver Kidney Uterus bone marrow What is HLA typing? -----CORRECT ANSWER-----------Refers to tissue type matching for transplant purposes ¤Goal is to match as many antigens as possible ¤A, B, & DR antigens clinically significant
lab values associated with burns -----CORRECT ANSWER-----------■Hyponatremia ■Hypernatremia ■Hyperkalemia Hypokalemia nursing management of burns -----CORRECT ANSWER-----------Acute Phase Monitor I&O Monitor bowel sounds Pain management Wound care: burns, skin grafts, debridement sites, escharotomy sites Nutritional therapy Rehabilitation phase Begins when the paitent's burn wounds are covered with skin or healed. The patient is able to resume a level of self-care activity Complications of burns -----CORRECT ANSWER-----------■Musculoskeletal system
- Decreased ROM / contractures ■Gastrointestinal system
- Paralytic ileus / constipation
- Diarrhea
- Curling's ulcer
- Positive stool occult blood ■Endocrine system
- ↑ Blood glucose levels
- ↑ Insulin production Phases of Burn Management -----CORRECT ANSWER-----------Acute Phase: Diagnostic tests Wound care Nutrition Infection prevention Pain management - IV route Tetanus Immunization Antimicrobial Agents DVT prevention Rehabilitative Phase:
Prevention of contractures and scars Resumption of roles ROM exercise Pain management for burns -----CORRECT ANSWER-----------IV is best, IM will not get absorbed. dauladid, morphine, fentanyl, percocet, toreador and gabapentin how long in the acute phase of burn care can edema in the upper airway occur ----- CORRECT ANSWER-----------2 days clinical manifestations of Hodgkins -----CORRECT ANSWER------------onset is insidious
- painless lymph node enlargement in the cervical, axillary or inguinal lymph nodes
- lymphadenopathy is not painful and nodes are movable
- night sweats, fever, weight loss and fatigue which are all called "B" symptoms and correlate with a poor prognosis key point for nurse to incorporate in beam radiation care plan -----CORRECT ANSWER- ----------inspect skin frequently cause of decreased in bp, hr and cardiac output as well as venous pooling in a patient suffering a spinal cord injury -----CORRECT ANSWER-----------loss of autonomic nervous system function areas of brain affected by coup-countercoup injury -----CORRECT ANSWER----------- frontal and occipital lobes assessment findings for urinary retention -----CORRECT ANSWER-----------frequency straining when initiating feeling of incomplete bladder emptying
Cardinal signs of brain death -----CORRECT ANSWER-----------Coma Absence of brain stem reflexes Apnea Primary tool to evaluate brain structure -----CORRECT ANSWER-----------MRI nursing interventions for autonomic dysreflexia -----CORRECT ANSWER------------ Elevate head of bed at 45 degrees, or sit patient upright
- Notify physician
- Assess cause
- Provide immediate catheterization assess Bp every 2-5 minutes remove binding devices or clothing monitor for runny nose common causes of autonomic dysreflexia -----CORRECT ANSWER-----------bladder distension bowel impaction breakdown of skin what is normal ICP -----CORRECT ANSWER----------- 5 - 15 mmHg factors that can increase ICP -----CORRECT ANSWER-----------hyperthermia hypoxia vomiting valsalva maneuver Explain the Monro-Kellie hypothesis -----CORRECT ANSWER-----------That if one of the three; blood, brain tissue, & CSF) is high the other two must be the opposite
what is normal cerebral perfusion pressure -----CORRECT ANSWER----------- 60 - 100 mmHg What is Cushing's triad? -----CORRECT ANSWER-----------widening pulse pressure bradycardia irregular respirations Mild Traumatic Brain Injury (MTBI) -----CORRECT ANSWER-----------Injury to head with either brief (less than 30 minutes) or no loss of consciousness; symptoms may include vomiting, lethargy, dizziness, and inability to recall recent events. GCS 13- 15 moderate traumatic brain injury -----CORRECT ANSWER------------ Characterized by LOC 30 min- 6 hrs and Glasgow Coma Scale (GCS) 9- 12
- Post traumatic amnesia may last up to 24 hours Severe traumatic brain injury -----CORRECT ANSWER-----------<8 on GCS LOC greater then 6 hours ABCDEs of melanoma -----CORRECT ANSWER-----------asymmetry, border, color, diameter, evolution what do you want MAP to be in a spinal cord injury -----CORRECT ANSWER----------- 85 and above nursing priority for spastic bladder -----CORRECT ANSWER-----------prevent skin breakdown first sign of neurogenic bladder -----CORRECT ANSWER-----------UTI
