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kdkrenik kdkrenik
wrote...
Posts: 354
Rep: 1 0
6 years ago
A patient is admitted with trauma to the integumentary system. Which type of skin trauma should the nurse prepare to assess?
 
  Select all that apply.
  1. cutaneous
  2. abrasion
  3. laceration
  4. contusion
  5. keloid

Question 2

A trauma patient is being assessed with the Champion Revised Scoring System. What assessment data should the nurse use with this scoring system?
 
  Select all that apply.
  1. diastolic blood pressure
  2. heart rate
  3. Glasgow coma scale
  4. systolic blood pressure
  5. respiratory rate

Question 3

The nurse is reviewing data for a patient experiencing shock. Based on these data, the nurse recognizes that the patient is in which stage of shock?
 
  1. compensatory
  2. early, reversible
  3. progressive
  4. refractory

Question 4

The nurse is planning care for a patient diagnosed with shock. Which intervention should the nurse include to address this patient's problem of anxiety?
 
  1. reducing stimuli and medicating for pain
  2. assessing blood pressure and heart rate
  3. monitoring central venous pressure
  4. assessing bowel sounds

Question 5

A female who was a victim of rape 6 months ago comes to an outpatient clinic for the treatment of posttraumatic stress disorder. Which data collected during the patient's assessment indicates a manifestation associated with this disorder?
 
  1. The patient described severe nightmares related to the event.
  2. The patient denied anger or shock.
  3. The patient denied the need for drug or alcohol counseling.
  4. The patient stated that her family is very supportive.

Question 6

The nurse suspects that a patient diagnosed with a myocardial infarction is developing cardiogenic shock. What manifestation did the nurse assess to come to this conclusion?
 
  1. jugular vein distention
  2. warm extremities
  3. laryngospasm
  4. urticaria
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Replies
wrote...
6 years ago
The answer to question 1

Correct Answer: 2, 3, 4

Abrasions, or partial-thickness denudations of an area of integument, generally result from falls or scrapes. Lacerations are open wounds that result from sharp cutting or tearing. Contusions, or superficial tissue injuries, result from blunt trauma that causes the breakage of small blood vessels and bleeding into the surrounding tissue. Cutaneous is a term used to refer to the integument, not to trauma to the skin. A keloid is a type of scar.

The answer to question 2

Correct Answer: 3, 4, 5

The Champion Revised Scoring System analyzes three elements: the Glasgow Coma Scale, systolic blood pressure, and respiratory rate. The patient receives a total score; the highest score is 12. Although the diastolic blood pressure and heart rate are part of the patient's assessment, they are not included in the Champion Revised Scoring System.

The answer to question 3

Correct Answer: 3
In compensatory shock, the blood loss is 750 mL, with up to 15 blood volume loss. Other indicators are normal or increased; the patient is only slightly anxious. In early reversible shock there is a blood loss of 7501500 mL, 1530 blood volume loss, heart rate >100, blood pressure normal, pulse pressure decreased, capillary refill and respiratory rate slightly increased, urine output 2030 mL/h. The patient is mildly anxious to agitated. The manifestations in progressive shock are: blood loss of 15002000 mL, 3040 blood volume loss, heart rate >120, blood pressure and pulse pressure decreased, capillary refill increased over normal, moderate tachypnea, urinary output below normal, and mental status altered. In refractory shock, the patient's condition has deteriorated markedly, with over 2,000 mL blood loss and >40 loss of blood volume.

The answer to question 4

Correct Answer: 1

Interventions appropriate for the problem of anxiety include reducing stimuli, which is calming and facilitates rest, and medicating for pain because pain precipitates or aggravates anxiety. Assessing blood pressure and heart rate would be appropriate for a problem with cardiac output. Monitoring central venous pressure would be appropriate for a problem with tissue perfusion. Assessing bowel sounds would be appropriate for a problem with cardiac output.

The answer to question 5

Correct Answer: 1
Posttraumatic stress disorder is an intense, sustained emotional response to a disastrous event. It is characterized by emotions that range from anger to fear, and by flashbacks or psychic numbing. In the initial stage, the patient can be calm or might express feelings of anger, disbelief, terror, and shock. In the long-term phase, which begins anywhere from a few days to several months after the event, the patient often experiences flashbacks and nightmares of the traumatic event. The patient also might call on ineffective coping mechanisms, such as alcohol or drugs, and withdraw from relationships.

The answer to question 6

Correct Answer: 1
Jugular vein distention is seen in cardiogenic shock. Warm extremities are seen in early septic shock and anaphylactic shock. Laryngospasm and urticaria are seen in anaphylactic shock.
kdkrenik Author
wrote...
6 years ago
White Heavy Checkmark Correct!
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