NUR 111: Session 18

Lesson Preview:

1. Rapid assessment
2. Immobilization
3. Extrication

Check for Understanding

1. Answer: C
Rationale: An increase in the urine output indicates that perfusion is improving.
2. Answer: D
Rationale: The client is suffering from hyperventilation secondary from anxiety. the initial action
is to let the client breathe in a paper bag that will allow the rebreathing of carbon dioxide.
3. Answer: D
Rationale: The priority goal is to increase myocardial oxygenation.
4. Answer: C
Rationale: Chest pain is considered an emergent priority. which is defined as potentially life-
threatening.
5. Answer: C
Rationale: Hypovolemic shock occurs when the volume of the circulatory system is too depleted
to allow adequate circulation to the tissues of the body. A fractured pelvis will lose about one liter
of blood hence symptoms such as hypotension. tachycardia. and tachypnea will occur.
6. Answer: A
Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury
(SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia.
7. Answer: C
Rationale: The Babinski reflex indicates typical neurological function in children under 1–2 years
old. If the Babinski reflex, or a positive Babinski sign, happens in children over 2 or in adults. This
can indicate underlying neurological conditions, nervous system disorders, or brain disorders.
8. Answer: C
Rationale: Reflex vasodilation below the level of the spinal cord injury places the client at risk for
orthostatic hypotension, which may be profound. Measures to minimize this include measuring
vital signs before and during position changes, use of a tilt-table with early mobilization, and
changing the client's position slowly.
9. Answer: C
Rationale: Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin
due to the loss of adrenergic stimulation below the level of the lesion.
10. Answer: B
Rationale: All clients with a head injury are treated as if a cervical spine injury is present until x-
rays confirm their absence. ROM would be contraindicated at this time.
11. Answer: A
Rationale: Administration of oxygen is always the highest priority
12. Answer: A
 Rationale: Type I hypersensitivity reactions can be seen in bronchial asthma, allergic rhinitis,
allergic dermatitis, food allergy, allergic conjunctivitis, and anaphylactic shock.
13. Answer: B
Rationale: Bronchodilators would help open the client’s airway and improve his oxygenation
status. Beta-adrenergic blockers aren’t indicated in the management of asthma because they may
cause bronchospasm. Obtaining laboratory values wouldn’t be done on an emergency basis. and
having the client lie flat in bed could worsen his ability to breathe.
14. Answer: A
Rationale: Since the stinger will continue to release venom into the skin. removing the stinger
should be the first action that the nurse should direct to the client.
15. Answer: A
Rationale: The client is hyperventilating secondary to anxiety, and breathing into a paper bag will
allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help.

Lesson wrap-up

Activity 1

• Monitor I&O closely. Estimate fluid loss and replace it as necessary

• Report immediately to the nurse or any health care provider if felt any signs of difficulty of
breathing, edema, and others.

Activity 2

We started the lesson by reading it, the topic was great and very informative. Our opportunities
for practice were enhanced since the purpose of the lesson is for us to learn more about the topic.