medical surgical ATI; general

Question 1

First Degree frostbite

Answer 1

superficial layers of exposed skin are affected with hyperemia and edema

Question 2

Second degree frostbite

Answer 2

blisters cover exposed skin causing narcotic tissue death and swelling.

Question 3

Third degree frostbite

Answer 3

extensive edema and blisters to the affected skin which does not blanch.
Treat by debridement of damaged tissue

Question 4

Fourth degree frostbite

Answer 4

affected area completely lacks blood supply
considered full thickness necrosis.
potential prognosis of gangrene.

Question 5

Nursing actions for frostbite

Answer 5

Bathe affected area in a warm bath (104-106 F/ 40-42 C)

Administer tetanus toxoid IM vaccine to prevent complications related to growth of tetanus in wounds.

Question 6

Hypothermia

Answer 6

occurs when client’s core temp. is 35 C (95 F) or less

victims of trauma- at risk due to exposure, unwarmed oxygen, and cold IV fluids

can lead to eventual coma, hypoxemia, and acidosis

Question 7

GCS

Answer 7

eye-opening response (4)

verbal response (5)

motor response (6)

Question 8

Heat Stroke: manifestations

Answer 8

• elevated temp. (>40 C or 104 F)
  -lack of perspiration
  -low BP
  -increased HR
  -decreased urinary output
  -alterations in mental status
  -abnormal blood potassium or sodium levels

Question 9

Common causes of PEA
5 h’s
5 t’s

Answer 9

1. hypovolemia
2. hypoxia
3. hydrogen ion accumulation, resulting in acidosis
4. hyperkalemia/ hypokalemia
5. hypothermai

1) toxins
2) tamponade (cardiac)
3) tension pneumo.
4) thrombosis (coronary)
5) thrombosis (pulmonary)

Question 10

MASLOW’S HIERARCHY OF NEEDS: 5 levels

Answer 10

1st-
2nd
3rd
4th
5th

Question 11

five-level system ED triage

Answer 11

resuscitation (level 1)
emergent (level 2)
urgent (level 3)
less urgent (level 4)
non-urgent (level 5)