3rd year semester 1 final exam

Question 1

Phlebitis

Answer 1

Inflammation
Mechanical (movement) & chemical (the actual fluid given)

Question 2

Late signs of ICP?

Answer 2

decreased LOC
bradycardia
irregular respirations
cheyne stokes respirations
decerebrate or decorticate posturing
fixed and dilated pupils

Question 3

what is stupor?

Answer 3

marked diminution in reactivity to environmental stimuli and can be aroused only by continual stimulation

Question 4

what are the stages of shock?

Answer 4

compensatory, progressive, irreversible

Question 5

what degree should the HOB be raised to with ICP?

Answer 5

approx. 30 degrees

Question 6

how do you figure out hourly infusion rate for a child?

Answer 6

100mL/kg for first 10 kg, 50mL/kg second 10kg, then 20mL/kg for remainder
divide all that by 24 to get the hourly rate

Question 7

early signs of ICP?

Answer 7

headache
vomiting
blurred or double vision
dizziness
decreased pulse and respirations
increased BP and pulse pressure
pupil reaction time decreased, unequal or both
changes in LOC, irritability

Question 8

how long is peripheral parenteral nutrition usually given?

Answer 8

5-7 days

Question 9

expected urine output for child?

Answer 9

1-2 mL/kg/hr

Question 10

Obtunded

Answer 10

decreased arousal and awareness, inability to follow commands

Question 11

what are some overall management strategies for shock?

Answer 11

respiratory support
fluid replacement - crystalloids (eg. NS, LR) to add more fluid, colloids (albumin) to expand blood volume
vasoactive meds
nutritional support (d/t metabolic demands)

Question 12

what is MAP and what is the norm?

Answer 12

Mean Arterial Pressure
CO x peripheral resistance
normal 70-105 mmHg

Question 13

what signs show that death is inevitable?

Answer 13

coma with fixed dilated pupils

impaired respirations

Question 14

what is the critical low of MAP and what does it mean?

Answer 14

65 mmHg or lower

inadequate perfusion

Question 15

why do we use IVs?

Answer 15

fluid replenishment
fast pain management
blood products

Question 16

what three things need to be adequate in order to properly perfuse tissues and organs?

Answer 16

cardiac pump
vasculature
blood volume

Question 17

what are ways ICP is managed?

Answer 17

Sedation, osmotic diuretics, restricting fluids, draining CSF, controlling fever, oxygenation, managing BP

Question 18

what are the s&s of hypovolemic shock?

Answer 18

Skin cold and clammy
Disoriented
Restless

Question 19

what is cushings reflex?

Answer 19

results from significant decrease in cerebral blood flow
increased arterial blood pressure - Causes rise in SBP (as high as 270)
widening of the pulse pressure
slowing of the heart rate

Question 20

coma definition

Answer 20

state of unarousable unresponsiveness

no purposeful responses to internal or external stimuli Comas usually last 2-4 weeks

Question 21

Persistent vegetative state

Answer 21

wakeful after coma but devoid of cognitive or affective mental function

Question 22

name three things that can cause altered LOC

Answer 22

• Alcohol
• Epilepsy/ electrolytes
• Infection
• Overdose
• Uremia
• Trauma
• Insulin
• Psychosis
• Stroke/ seizures

Question 23

Hematoma

Answer 23

collection or pocket of blood

Question 24

Shock

Answer 24

end organs receive insufficient oxygenation for normal metabolic processes

Question 25

what are the types of altered LOC?

Answer 25

neurologic toxicologic metabolic

Question 26

how often should an IV site be changed in an adult?

Answer 26

q72-96 hours

Question 27

what is cushings triad?

Answer 27

Bradycardia, HTN, irregular breathing pattern | Herniation, occlusion of blood flow

Question 28

s and s of compensatory shock

Answer 28

``` cool & clammy skin decreased urinary output no bowel sounds increased respiratory rate narrowing/decreased pulse pressure ```

Question 29

Infiltration/extravasation

Answer 29

when fluids are leaking outside the IV. Certain fluids can cause damage in the tissues around the site

Question 30

what are reasons to use a central line?

Answer 30

lack of peripheral access longer term irritating solutions rapid dilution

Question 31

which type of altered LOC includes an abnormal papillary response?

Answer 31

neurologic

Question 32

pH compatible with life?

Answer 32

6.8 - 7.8

Question 33

what's a nursing action that you can do during compensatory shock?

Answer 33

apply supplemental oxygen | decreased metabolic demand

Question 34

what is the normal range of bicarb?

Answer 34

19-25

Question 35

what are some characteristics of progressive stage of shock?

Answer 35

decreased MAP significant drop in SBP (<90 or 40 below baseline) interstitial edema (pulmonary edema), SOB & crackles low o2 sat high RR tachycardia chest pain

Question 36

locked-in syndrome

Answer 36

lesion affecting the pons results in tetraplegia inability to speak vertical eye movements and lid elevation remain intact

Question 37

what scenario would intraosseous infusion be used for?

Answer 37

emergency such as burn (pediatric clts)

Question 38

what are the two types of circulatory shock?

Answer 38

sepsis & anaphylactic

Question 39

Akinetic mutism definition

Answer 39

unresponsiveness | patient makes no voluntary movement or sound sometimes opens eyes

Question 40

what needs to be kept in mind when discontinuing central TPN?

Answer 40

abrupt d/c can lead to a drop in blood glucose d/t the dextrose in the sol'n