Questions and Answers
What is a characteristic of sudden loss of consciousness?
What should be the priority nursing action for a patient with multiple organ dysfunction syndrome (MODS) due to shock?
What symptom would indicate the need to take a form of glucose in a patient with diabetes mellitus?
What is the purpose of asking 'what time was the patient last fully functional' in a patient with acute onset of facial drooping and slurred speech?
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What is the primary purpose of an escharotomy?
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What is a sign of respiratory distress?
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What is a priority nursing action for a patient with multiple organ dysfunction syndrome (MODS)?
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What is a characteristic of cardiac tamponade?
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What is the correct way to remove dead tissue from a burned area?
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What is the infusion rate in ml/hr that the nurse should set for the gentamycin dose?
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Which patient statement indicates that the nurse's nutritional teaching plan has been effective for a low-sodium diet?
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What is a common initial symptom of HIV infection?
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What should the nurse do before applying new wound dressings to a patient with burns on their upper thighs and knees?
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What is the purpose of making large incisions in the eschar of a burned patient?
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What is the goal of a low-sodium diet for a patient with heart failure?
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What is the primary focus of postoperative care for a burned patient?
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Which of the following is NOT part of the primary survey when initially assessing a patient in the emergency room?
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Which patient has the LEAST risk of developing acute respiratory distress syndrome (ARDS)?
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Why may a patient with hemorrhagic stroke not receive clot-busting medication (tPA)?
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What is a common complication of modified radical mastectomy?
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What does constant tiddling in the water-seal chamber of a closed chest-drainage system indicate?
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What is a common site of metastasis for cancer cells?
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Why should blood pressure be obtained from the unaffected arm in a client undergoing mastectomy?
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What is the primary goal of elevating the affected arm and hand in a client undergoing mastectomy?
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Study Notes
Sudden Loss of Consciousness
- Muffled heart sounds
- Paradoxical chest wall movement with respirations
- Diminished or absent breath sounds on the affected side
Nursing Priorities
- Providing clear information and emotional support to the family of a patient with multiple organ dysfunction syndrome (MODS) due to shock
Diabetes Mellitus
- Diaphoresis, palpitations, and shakiness are symptoms of hypoglycemia
- Hot, dry skin, polyuria, and fruity breath odor are symptoms of hyperglycemia
Acute Onset of Facial Drooping and Slurred Speech
- Assessing the time the patient was last fully functional is important in determining the prognosis of a hemorrhagic stroke
Escharotomy
- Large incisions are made in the eschar to improve circulation
Medication Administration
- To administer 1mg/kg of gentamycin IV 8h, the nurse would set the infusion pump at 200ml/hr for a 90kg patient
Heart Failure
- A low-sodium diet is recommended for patients with heart failure
- Avoiding ham and cheese sandwiches, salads with cheese and croutons, and chicken noodle soup with crackers is important
HIV and AIDS
- Flu-like symptoms are initial manifestations of HIV infection
Burn Care
- Assessing peripheral pulses distal to the dressing and administering PRN analgesia as ordered are important nursing actions before applying new wound dressings
- Instructing the patient to keep the wound site in a dependent position and assisting with passive range of motion exercises are also important
Primary Survey
- Assessing breathing, level of consciousness, and circulatory status by checking pulse and blood pressure are part of the primary survey
Acute Respiratory Distress Syndrome (ARDS)
- A 70-year-old adult who is septic has the greatest risk of developing ARDS
Hemorrhagic Stroke
- Clot-busting medication (tPA) may not be administered due to the risk of causing more bleeding
Cancer
- The liver is one of the most common metastasis sites for cancer cells
Breast Cancer
- Postoperatively, blood pressure should be obtained from the right arm, and the client's left arm and hand should be elevated as much as possible to prevent lymphedema
Closed Chest-Drainage System
- Constant tiddling in the water-seal chamber indicates that the system is functioning normally
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Description
This quiz focuses on the nursing priority in caring for a patient with multiple organ dysfunction syndrome (MODS) due to shock in an ICU setting.
