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• HCP orders for client diagnosed with septicemia


  1. Provide clear liquid diet

  2. Initiate IV antibiotic therapy

  3. Obtain a STAT chest x-ray

  4. Perform hourly glucometer checks
• The HCP order with the highest priority is
• UAP action that warrants intervention by the RN

  The UAP places a urine specimen in a biohazard bag in the hallway
• Shock


  The compensatory stage
• Palliative care


  Aims to relieve or reduce the symptoms of a disease
• Mannitol


  Medication used to treat increased intracranial pressure
• Short backboard or vest-style immobilization device


  Indicated for patients who require prompt extrication from an automobile
• NATO triage system - level red


  Injuries are life-threatening but survivable with available interventions
• Retrograde amnesia


  A patient who cannot remember the events that preceded his or her head injury
• Skull fractures


  Least likely to present with palpable deformity or other outward signs: basilar
• Cushing's triad


  Blood pressure 200/100 mmHg, pulse 140 beats/min, respirations 28 breaths/min
• Common signs of a skull fracture do not include superficial scalp lacerations
• What the nurse can do to best aid the family of a client in the end stage of terminal cancer
• Cervical collar


  Should not be removed unless sensory and motor functions remain intact
• The most important referral for the nurse to implement for the older male client with dementia
• Nerves that allow sensory and motor impulses to be sent from one nerve directly to another

  Connecting nerves
• Laboratory data that require the nurse to notify the HCP for the client with septicemia
• Voluntary activities


  Controlled by the somatic nervous system
• Information the nurse should include in a presentation on biological warfare
• Nerves that carry information from the body to the brain via the spinal cord

  Sensory nerves
• Intervention for a client with PTSD when resting

  Call the client's name to awaken him or her, but don't touch the client
• Spinal cord


  Encased in and protected by the spinal canal
• Effectiveness of positive-pressure ventilations


  Can only be determined by immediate reassessment following the intervention
• Best-protected part of the CNS

  Brain stem, controls cardiac and respiratory systems
• Primary assessment of unconscious head trauma patient

  1. Assist ventilations with bag-mask device

  2. Suction oropharynx

  3. Immobilize spine and transport immediately
• Sympathetic nervous system does not produce pupillary constriction
• Secondary brain injury


  Caused by hypoxia and hypotension, not immediate impact
• Primary assessment of semiconscious closed head trauma patient

  Apply 100% oxygen via nonrebreathing mask and obtain baseline vital signs
• Tough, fibrous outer meningeal layer

  Dura mater
• Lacerations to the scalp may be an indicator of deeper, more serious injuries
• Decreased sensory function is a common sign and symptom of a serious head injury
• When assessing a conscious patient with an MOI that suggests spinal injury, you should determine if the strength in all extremities is equal
• Peripheral nervous system


  Consists of 31 pairs of spinal nerves and 12 pairs of cranial nerves
• Immobilizing a child on a long backboard

  1. Secure the head prior to securing the torso and legs

  2. Place the child's head in a slightly extended position

  3. Place padding under the child's shoulders as needed
• Cerebral concussion


  Temporary loss or alteration of part or all of the brain's abilities to function without physical damage to the brain
• Most reliable sign of a head injury

  Decreased level of consciousness
• Moderate elevation in intracranial pressure with middle brain stem involvement

  Sluggishly reactive pupils, widened pulse pressure, bradycardia, and posturing
• No correct answers
• After assuming manual in-line stabilization of the patient's head

  1. Apply an appropriately sized rigid cervical collar

  2. Assess distal neurovascular status in the extremities
• Airway management for patient with suspected spinal injury and reduced tidal volume

  Ventilation assistance to maintain an oxygen saturation of 90%