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NURS3101 Exam Prep Questions With
Verified Answers
CT (computerised' tomography) - ANSWER CT combines a series of x-ray images taken from different angels and uses computer processing to create cross sectional images or slices of the bone, blood vessels and soft tissue inside your body Anoxia - ANSWER an absence or deficiency of oxygen reaching the tissues = severe hypoxia cyanosis - ANSWER a bluish discolouration of the skin due to poor circulation or inadequate oxygenation if the blood dyspnoea - ANSWER breathing difficulty, breathlessness, laboured breathing, shortness of breath ecchymosis - ANSWER a discolouration of the skin resulting from bleeding underneath, typically caused by bruising Hypoxia - ANSWER reduction of oxygen supply to a tissue below physiological levels despite adequate perfusion of the tissue by blood laryngeal oedema - ANSWER a frequent complication of intubation. it often presents shortly after extubation as a post-extubation stridor and results from damage to the mucosa of the larynx. mucosal damage is caused by pressure and ischemia resulting in an inflammatory response laryngospasm - ANSWER is a brief spasm of the vocal cords that temporarily makes it difficult to speak or breathe. the onset of vocal cord spasms is usually sudden and the breathing difficulty can be alarming lumbar puncture - ANSWER a small needle inserted into the spinal canal to obtain a sample of spinal fluid for testing MRI (magnetic resonance imaging) - ANSWER a radiological test that uses magnetic field and radio waves to create detailed images of the organs and tissues in your body Pharyngeal oedema - ANSWER swelling of the pharynx, the tube connecting the mouth to the oesophagus snoring - ANSWER snoring occurs when air flows past relaxed tissues in your throat causing the tissues to vibrate as you breathe which creates snoring and grunting dounds stridor - ANSWER a harsh vibrating noise when breathing caused by obstruction of the
windpipe or larynx wheezing - ANSWER breath with a whistling or rattling sound in the chest as a result of resulting of obstruction in the air passages X-Ray - ANSWER a radiological test where x-ray beams are passed through the body to produce images of body structures particularly bones What does the A-G algorithm stand for - ANSWER Airway Breathing Circulation Disability Environment/Exposure Fluids Glucose What are the 4H's and 4T's? - ANSWER Hypoxia Hypovolemia Hyper/hypokalaemia/metabolic disorders Hypothermia Tension pneumothorax Cardiac Temponade Toxic substances Thromboembolism What consists of an airway assessment - ANSWER Look for - Airway obstruction, accessory muscle use, tracheal tug, intercostal recession, Paradoxial chest, abdominal wall movement, listen for - speech, abnormal breathing sounds what is a breathing/respiratory assessment - ANSWER Chest wall movement, depth and rate and rhythm of respirations, cyanosis, jugular venous pressure, pulse oximery breathing sounds, cough what is a circulation assessment - ANSWER Pallor, Peripheral cyanosis, skin mottling, skin temperature, heart rate, pulse strength and rhythm, BP, Capillary refill time
People who are critically ill, suffering critical injury or cardiac arrest. in the Australian Triage scale what is classed as a category 2 or emergency category - ANSWER needs to be treated within 10 minutes people suffering critical illness or severe pain serious chest pain, difficulties breathing, severe fractures in the Australian Triage scale what is classed as a category 3 or urgent category - ANSWER needs to be treated within 30 minutes people suffering severe illness, bleeding heavily from cuts, have major fractures or dehydrated in the Australian Triage scale what is classed as a category 4 or semi urgent category - ANSWER needs to be seen within 1 hour people who have less severe symptoms or injuries e.g. foreign body in eye, sprained ankle, migraine or earache in the Australian Triage scale what is classed as a category 5 or non urgent category - ANSWER needs to be seen within 2 hours people who have minor illnesses or symptoms that have been present for more than 1 week such as rashes or minor aches and pains. what does MIST stand for - ANSWER Mechanism Injuries Signs and symptoms Treatment
Used for ED handover from ambulance
what are some special considerations with triaging? - ANSWER Pregnant mental health intoxication frequent flyers extremities of age sepsis
injury DNW (did not wait)
what is a disaster - ANSWER A serious disruption to community life which threatens or causes death or injury in that community which is beyond day to day capacity. requires special mobilisation, and organisation of resources more than those normally available.
what is a priority 1- red category - ANSWER casualties who require immediate life saving procedures
what is a priority 2- yellow category - ANSWER casualties who require definitive treatment within 4-6 hours
what is a priority 3 - green category - ANSWER less serious categories who do not require treatment within other time limits
what is the black category - ANSWER deceased person can be declared by an ambulance officer or a nurse
what is the blue category or 4th category - ANSWER casualties whose condition is so severe that they can not survive despite the best available care
what are some airway devices - ANSWER oropharyngeal airway (guedels airway) Laryngoscope Nasopharyngeal tubes Laryngeal mask endotracheal tube
in association of the care of an intubated patient in ICU what does FAST HUGS IN BED stand for - ANSWER Fluid therapy and feeding
infection
why are arterial lines used - ANSWER close monitoring of CVP used for pts who are haemodynamically unstable allows for regular and easy ABGs
what are complications of arterial lines - ANSWER haemorrhage thrombosis infection emboli medication error ischaemic distal extremities pressure area development
what is a peripheral inserted central catheter used for - ANSWER for long term IV antibiotics, fluids, medication, nutrition and blood collection
what are complications for PICC lines - ANSWER air embolism infection phlebitis catheter malposition thrombus formation difficult removal nerve injury leakage catheter tip breaking
what are whole book products used for - ANSWER replace blood lost in haemorrhage
what are packed red blood cells used for - ANSWER increasing oxygen carrying capacity without excess fluid
what is plasma used for - ANSWER used to restore fluid and protein lost from intravascular space also used to treat coagulation disorders
what are platelets used for - ANSWER used to assist with clotting abnormalities
what is serum albumin used for - ANSWER used to increase osmotic pressure in the intravascular space causing a fluid shift from the interstitial to the intravascular space to restore blood volume
what are cryoprecipitate used for - ANSWER a solution containing factor 8 the clotting factor haemophiliacs are missing
what is shock - ANSWER an altered physiological state that can affect the functioning of every cell and organ system in the body. it is a complex syndrome reflecting decreased blood flow to tissues with resulting cellular dysfunction and eventual organ failure
what is hypovolemic shock - ANSWER fluid loss e.g. dehydration, severe vomiting/diarrhoea fluid shift e.g. burns haemorrhage - internal or external
what is cariogenic/obstructive shock - ANSWER pump failure e.g.. MI, angina, valvular heart disease, CCF, severe arrhythmia obstructive to flow e.g. clot, tumour, cardiac tamponade, tension pneumothorax, pulmonary embolism
skin = cool pale normal turgor oedema = systemic blood volume = relative hypovolemia
what are the symptoms of septic shock - ANSWER heart rate = increased TPR = decreased skin = hot pink normal turgor oedema = systemic blood volume = relative hypovolemia
what categorises stage 1/compensatory stage of shock - ANSWER tachycardia feeling of weakness, sickness, hot/cold, fear, sense of impending doom nausea and dizziness reducing urine output changes in mental capacity thirst skin become cold and clammy and cyanotic increased depth of breathing dyspnoea/ tachypnoea decreased CO
what categorises stage 2 / progressive stage of shock - ANSWER tachycardia weak, thready pulse listlessness confusion apathy slow speech decreased BP moderate to severe orthostatic pressure chest pain
metabolic acidocis hyperventilation possible hypotension
what categorises stage 3 / irriverable stage of shock - ANSWER confusion, disorientation, slurred speech, unconsciousness slow irregular thready pulse falling BP
what is lactate acidosis - ANSWER tissue hypoxia causes cells to perform anaerobic metabolism which produces lactate which can convert into lactic acid. a build up of tactic acid can lead to lactic acidosis
what is treatment for shock - ANSWER ABCDE provide high flow o2 via non-rebreather assess vital signs GCS, ECG, BGL, Cardiac monotoring Bloods (Hg, Hct, ABG, Lactate Fluid status
Treatment for hypovolemic shock - ANSWER insert 2 large bore IVCs and infuse warmed isotonic crystalloid solution control haemorrhage Normal shock treatment administer blood product
treatment for cariogenic shock - ANSWER correct underlying cause emergency cardiopulmonary bypass
what is toxaemia - ANSWER blood poisoning by toxins from a local bacteria infection
what is bacteraemia - ANSWER the presence of bacteria in the blood
what is toxic shock syndrome - ANSWER caused by staphylococcus and associated with tampon use and reproductive tract infection
what are causes of sepsis - ANSWER wounds surgery trauma devices infection
what are sepsis risk factors - ANSWER elderly and newborn people with underlying disease major surgery, trauma, burns invasive procedures immunosuppressed people
what is the pathophysiology of sepsis - ANSWER exaggerated immune / inflammatory and procoagulants response on a systemic level massive vasodilation increased capillary permeability relative hypovolemia increased blood viscosity clotting
what are sepsis signs and symptoms - ANSWER tachypnoea
tachycardia fever >38 to hypothermia < acute oliguria METABOLIC ACIDOSIS acute encephalopathy altered LOC or change in cognitive status hypotension systolic arterial pressure < MAP < lactate >4mmol/L
What is treatment for sepsis - ANSWER fluid resuscitation administration of antibiotics (test for gram+ or gram- monitor blood cultures/lactate levels monitor urinary output investigate sources of infection maintain Spo2 >95% monitor vital signs
what are complications of sepsis - ANSWER single organ failure multiple organ dysfunction syndrome Disseminated intravascular coagulation triad of death (hypothermia, acidosis, coagulopathy
what are the 4 sections of the spinal column - ANSWER cervical thoracic lumbar
what is efferent - ANSWER moto information sent from the brain stem to the muscles and organs
what does level C1-C4 control - ANSWER diaphram, intercostal and abdominal muscles
what are the 6 Spinal cord injury mechanisms - ANSWER flexion extension compression rotation contusion penetrating
how is a spinal cord injury diagnosed - ANSWER x-ray MRI CT reflex testing
what functions are affected by spinal cord injuries - ANSWER spinal reflexes ventilation autonomic nervous system temperature regulation oedema and DVT motor control skin integrity pain reception bladder and bowel function sexual dysfunction
what is a lower motor neuron injury - ANSWER Somatic cell body located in motor nucleus of the brain or spinal cord Flaccid and paralysis of muscle has no information is being sent to the brain
what is an upper motor neuron injury - ANSWER somatic cell body lies in a CNS processing centre involuntary movement inappropriate to the stimulus as there is no commands being transmitted from the brain
what is autonomic dysreflexia - ANSWER a potentially dangerous syndrome that affects spinal cord injury patients at or above T6 which results in acute and uncontrolled hypertension
pathophysiology of autonomic dysreflexia - ANSWER signal transmitted up the spinal cord initiating massive reflex sympathetic activation causing widespread vasoconstriction brain detects a sudden rise in BP, brain responds and causes bradycardia to compensate.
signs and symptoms of autonomic dysreflexia - ANSWER above the injury SOB flushed nasal congestion blurred vision chills without fever headache
below the injury
what is intracranial pressure - ANSWER the pressure within the skull normal = 7-15mmHg (adults) 1-7mmHg (children) 1.5-6mmHg (Infants) severe= >20mmHg
what causes an increase in cranial tissue volume - ANSWER tumour abnormal growth inflammation/infection
what causes an increase in CNF - ANSWER Blood, increased WBC, tumour cells or protein in CNF
what is the cerebral perfusion pressure - ANSWER the pressure needed to perfuse the brain with blood Normal = 70-90mmHg
what is Cerebral blood flow - ANSWER the amount of blood the brain is receiving
what is cerbrovascular resistance - ANSWER the pressure across the cerebrovascular bed from the arteries to the jugular vein
what is central venous pressure - ANSWER measured in the central veins close to the heart, it is an estimate of right ventricular preload
what are signs and symptoms of rising intracranial pressure - ANSWER confusion disorientation restlessness or lethargy mild pupal dilation, sluggish response to light some muscle weakness
Nerve palsy papilloedema headache (worse when lying down) vomiting without nausea blurred vision coma pupillary dilation on side of lesion non reactive to light hemiplegia
what is cushing's triad - ANSWER a sign of rising intracranial pressure widening pulse pressure between the systolic BP and Diastolic BP bradycardia increased or regular resps
what are the classifications of traumatic brain injury - ANSWER mechanism of injury = open or closed head injury extent of injury = focal or diffuse types of brain injury : primary - contusion or lacerations secondary - haemorrhage concussion diffuse axonal injury
what are symptoms of an anterior fossa skull fracture - ANSWER rhinorrhoea - discharge from the nose raccoon eyes anosmia (loss of smell) oculomotor palsies
