NUR 347 Final Exam 1
- what are some things that are included in the primary assessment of
a patient in a motor vehicle accident?
Answer
ABCDE (airway, breathing, circulation, disability, exposure)
- what do we add in our ABC's if its a trauma patient?
Answer
D & E (disability and exposure)
- what should we assess for in a severe leg trauma patient?
Answer
assess for circulation
- in a severe leg trauma patient, what do we do if the pedal pulse is palpable and there is
swelling?
Answer
assess further for signs of decreased circulation
- what are the 5 P's ?
Answer
pallor pulse 1 / 3
paralysis paresthesia pain
- what always applies in ER patients?
Answer
ABC's (add D & E if trauma)
- paradoxical chest movement or flail chest movement are signs of what?
Answer
-
sign of a respiratory issue
- abdomen and chest move in opposite manner - outward during exhalation and inward during
inspiration
Answer
paradoxical chest movement
- fracture of two or more adjacent ribs in two or more places with loss of chest wall stability
Answer
flail chest
- clinical manifestations
Answer 2 / 3
-paradoxical movement of chest wall -respiratory distress
-may be associated with hemothorax, pneumothorax, pulmonary contusion
Answer
-
flail chest
- what are some nursing interventions for a patient with flail chest move- ment?
Answer
- O2 as needed to maintain O2 saturation
-stabilize flail segment with positive pressure ventilation (intubation and mechanical ventilation) -treat associated injuries -surgical fixation
- what will you see in a collapsed lung?
Answer
you will see paradoxical chest move- ment
- what may a patient need for a hemothorax or pneumothorax?
Answer
the patient with need a chest tube
- blood in the pleural space
- / 3