ICU final bonus review questions

A 10 year old girl suffered a partial thickness scalp burn over most of her anterior thighs and lower legs. What admission assessment would suggest to the nurse that shock was occurring?

tachycardia, hyperventilation

Which of the following signs of increased intracranial pressure (IPC) would appear first after head trauma?

restlessness and confusion

A patient is hospitalized following a T-4 injury. His spine has been surgically stabilized. The patient complains of a severe pounding headache and is profusely diaphoretic. The nurse's best intervention is to:

place the patient immediately in a sitting position

A nurse in the emergency department is observing a 4 year old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?

repeated vomiting

A teen-aged bicycle rider is hit by a truck traveling at a high rate of speed. On the emergency department her blood pressure is 80/50 mmHG, HR 140 BPM, respiratory rate is 8 breaths per minute, and a GCS score of 4. The nurse should anticipate that the first step in managing this patient is to:

perform endotracheal intubation

An adult arrives in the emergency department after a motor vehicle crash. She is immobilized on a backboard with a cervical collar. She has an obvious deformed left ankle and is complaining of abdominal pain. Her VS are BP 100/70, HR 112, RR 24. What is the first action by the nurse?

start an IV

A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment?

monitor respiratory effort and oxygen saturation level

A male patient with multiple injuries has had his airway stabilized and is breathing on his own. The nurse does not see any bleeding, but suspects internal hemorrhage when the patient:

has increased pulse rate

A client presents to the emergency department after hitting his head on the floor during a basketball game. The nurse obtains a GCS as follows- best eye opening = 3, best verbal response =4, best motor response = 6, total GCS = 13. How does the nurse interpret these findings?

opens eyes to verbal command, confused, and obeys commands

A 43 year old male is admitted to the MICU. VS are - HR 80, respiratory rate 24, and BP 140/100. He is lethargic and has a urine output of less than 10 mL per hour. Serum Na of 130, serum K of 3.2, and serum osmolarity of 245. The clinical picture is most consistent with:

SIADH

A 25 year old has sustained a head injury from a motor vehicle accident. The nurse notes that his ICP is elevating. Which of the following interventions should the nurse perform to decrease his ICP? Select all that apply

administer mannitol as ordered

maintain neutral neck alignment

While monitoring a burn victim, which of the following is considered the gold standard to evaluate burn resuscitation?

an adult urine output that is approximately 0.5-1.0 ml/kg/hr

Based on your analysis of this ABG - pH 7.26, PaO2 60, PaCO2 70, HCO3 26, what collaborative intervention do you anticipate?

endotracheal intubation and mechanical ventilation

A 20 year old female client is brought to the ER by her boyfriend, complaining of SOB and a fluttering feeling in her chest. Her ECG pattern shows a rapid HR (220 BPM) with QRS complexes measuring 0.08 seconds. The nurse prepares to administer:

adenosine

The nurse is admitting a client with multiple stab wounds sustained during a gang fight to the ED. The nurse knows that it would be MOST appropriate to obtain initial IV access by establishing a

16G catheter in each AC

what region of the spine is most susceptible to injury?

cervical

Jeff has a C4-C5 fracture. Which is correct?

he will need lifelong mechanical ventilation

The physician has ordered a solumedrol infusion for a patient with a spinal cord injury. Solumedrol has been shown to be effective in

improving motor and sensory function

A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. For which early clinical manifestation of acute respiratory distress syndrome should the nurse monitor

increase in RR from 18-26 breaths per minute

Mr T admitted to the SICU following an MVC. The initial drainage from a chest tube is 400CC. The following hour the chest tube drains 300CC of blood. Which is the most appropriate action by the nurse

notify the physician

The nurse is caring for a client who required chest tube insertion for a pneumothorax. The nurse is aware that the best test to assess for a pneumothorax resolution is

CXR

A patient arrives in the ER. He is tachy and hypotensive. He says I have a knife in my chest and I have Beck's triad: muffled heart sounds, JVD, and hypotension. I think I have a cardiac tamponade. Do you think that's true?

True

A patient with a T6 injury 3 months ago develops facial flushing and a BP of 210/106. After elevating the HOB, which is the most appropriate nursing action?

asssess for distended bladder

Your trauma patient has a spinal cord transection at the T1 level. The primary nursing action is

cardiovascular status

Which of the following is descriptive of a concussion?

it is a transient neuronal dysfunction

Your client is transported to the ED after sustaining head, back, and chest injuries when he fell 25 ft from a tree. The primary survey has been completed. His BP drops to 80/40, HR 56, RR 20. BBS are = and clear. SAO2 99%. This data is most consistent with

neurogenic shock

Autonomic dysreflexia is an emergency because

severe vasoconstriction occurs

An adult arrives in the ED after being assaulted with a baseball bat. He is intubated and becoming progressively more difficult to ventilate. suddenly he becomes unresponsive and pulseless. What is the priority intervention?

relieving the tension pneumothorax

A 44 yo man is admitted to the burn unit with second and third degree burns on 60% of his body. After 12 hours, his urine output is 24cc/hr. His ABG is: pH 7.31, PaO2 96, PaCO2 36, HCO 18. The nurse concludes that

he is in renal failure and metabolic acidosis

When admitting the trauma patient with a diagnosis of pelvic fracture to the ICU, the nurse's initial concern will focus on

hemorrhage control

A 72 yo female was hit by a car and was admitted to the ER with bilateral femur fractures. The priority nursing concern is

shock

A patient with a major burn receives TPN. The primary reason for this is

to ensure adequate calories and protein