SIRS and Emergency Nursing Concepts

Front

After a mass casualty event, which client will the nurse triage with a yellow tag? Options: 29-year old with third-degree burns over 80% of the body, 36-year old with closed fractures of both legs, 48-year old with wheezing and difficulty breathing, 52-year old with multiple abrasions and contusions

Back

36-year old with closed fractures of both legs

Front

Which of the following is a key indicator of septic shock in a patient? A sudden drop in blood pressure that does not respond to fluid resuscitation, A rapid decrease in heart rate, Decreased respiratory rate with normal oxygen saturation, Stable blood pressure despite a rise in body temperature

Back

A sudden drop in blood pressure that does not respond to fluid resuscitation

Answer explanation

A sudden drop in blood pressure that does not respond to fluid resuscitation

Front

Which of the following is a characteristic feature of Systemic Inflammatory Response Syndrome (SIRS)?
Options:
Blood pressure consistently above 120/80 mmHg
A temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F)
A heart rate below 60 beats per minute
Decreased respiratory rate with normal arterial blood gas levels

Back

A temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F)

Front

In the progressive phase of septic shock, the body experiences a significant decline in organ perfusion, leading to _______ (a condition where there is an accumulation of lactic acid in the bloodstream) and _______ (reduced urine output)

Back

lactic acidosis, oliguria

Answer explanation

In the progressive phase of septic shock, the condition worsens as the body's compensatory mechanisms begin to fail. During this phase, the body is no longer able to maintain adequate perfusion of vital organs, leading to a cascade of events that result in organ dysfunction.

Decreased Perfusion: As the shock becomes more severe, the blood pressure continues to drop despite fluid resuscitation. This reduced perfusion leads to hypoxia (lack of oxygen) in tissues and organs, impairing their function.

Elevated Lactate Levels: Lactic acidosis is a hallmark of the progressive phase. As cells become oxygen-starved, they switch to anaerobic metabolism, resulting in the production of lactate. Elevated lactate levels are an important indicator of poor prognosis.

Hypoperfusion of Kidneys: As septic shock progresses, blood pressure drops and the body's compensatory mechanisms become less effective. This results in decreased blood flow (perfusion) to the kidneys, which are highly sensitive to changes in blood flow. When the kidneys receive less blood, they cannot filter waste products or produce urine efficiently.

Front

In the early stages of sepsis, a patient may exhibit which of the following skin temperature changes? Cool, pale skin due to vasoconstriction, Cyanotic skin with mottling, Warm, flushed skin as a result of vasodilation, Cold, clammy skin with poor capillary refill

Back

Warm, flushed skin as a result of vasodilation

Answer explanation

In the early stages of sepsis, warm, flushed skin occurs primarily due to vasodilation, which is the widening of blood vessels. This happens as part of the body's initial response to infection and inflammation.

However, this warm and flushed skin is usually seen in the early stages of sepsis, where the body is still attempting to compensate for the infection. As sepsis progresses, blood pressure may drop, leading to cooler, pale skin due to vasoconstriction (narrowing of blood vessels) as the body tries to prioritize blood flow to vital organs.

Front

Which of the following clinical manifestations is most commonly associated with neurogenic shock?
Options: Rapid, shallow respirations with increased heart rate, Elevated blood pressure with a bounding pulse, Severe hypotension with a bradycardic heart rate, Cool, clammy skin with weak pulses

Back

Severe hypotension with a bradycardic heart rate

Answer explanation

In neurogenic shock, severe hypotension (low blood pressure) and bradycardia (slow heart rate) occur due to the loss of sympathetic nervous system (SNS) tone and the resulting imbalance between the parasympathetic and sympathetic nervous systems

• Neurogenic shock typically results from a spinal cord injury (especially above T6) or severe damage to the central nervous system (CNS), which disrupts the sympathetic nervous system's ability to regulate vascular tone.

• The SNS normally helps maintain vasoconstriction (narrowing of blood vessels) to keep blood pressure stable, especially during stress or injury.

• In neurogenic shock, the sympathetic outflow is lost, leading to vasodilation (widening of blood vessels) and a dramatic decrease in vascular resistance, causing a drop in blood pressure (hypotension).

• Normally, when blood pressure drops, the body compensates by increasing heart rate (tachycardia) through the sympathetic nervous system. However, in neurogenic shock, the sympathetic pathways that usually stimulate the heart are disrupted, and the parasympathetic nervous system (which causes the heart rate to slow) takes over.

• This results in bradycardia, where the heart rate slows down significantly, which is the opposite of what would occur in other types of shock (such as hypovolemic or septic shock, where tachycardia is common).

Front

A patient with a spinal cord injury at the T6 level presents with a sudden onset of severe hypertension, a headache, and profuse sweating above the level of injury. The nurse suspects autonomic dysreflexia. Which intervention should the nurse implement first?

Back

Sit the patient upright and check for the source of irritation below the level of injury.

Answer explanation

Sitting the patient upright during autonomic dysreflexia (AD) is an important intervention because it helps lower blood pressure and reduce the risk of stroke or other complications associated with severely high blood pressure.

severely high BP

flushed face

headache

decreased HR

increased sweating

distended neck veins

Front

A patient with a traumatic brain injury is suspected of having increased intracranial pressure (ICP). Which findings would most likely be observed? Options: Rapid pulse, normal blood pressure, and alertness; Hyperventilation, shallow breathing, and decreased blood pressure; Tachycardia, hypotension, and hyperreflexia; Bradycardia, widened pulse pressure, and altered level of consciousness.

Back

Bradycardia, widened pulse pressure, and altered level of consciousness

Answer explanation

Increased intracranial pressure (ICP) typically presents with signs such as Cushing's triad, which includes bradycardia, widened pulse pressure (the difference between systolic and diastolic blood pressure increases), and altered level of consciousness. This combination is a late and ominous sign of increased ICP. Other potential symptoms may include headache, vomiting, and papilledema.

Front

Which of the following safety precautions should the nurse implement before performing a lumbar puncture on a patient? Options: Ensure the patient is NPO for at least 12 hours prior to the procedure., Confirm that the patient has no signs of increased intracranial pressure (ICP)., Administer a pre-procedure sedative to ensure patient comfort., Place the patient in a prone position to increase spinal access.

Back

Confirm that the patient has no signs of increased intracranial pressure (ICP).

Answer explanation

Before performing a lumbar puncture, it is essential to rule out increased intracranial pressure (ICP). Performing a lumbar puncture in a patient with elevated ICP can cause brain herniation due to the sudden pressure change when the cerebrospinal fluid (CSF) is removed. Therefore, it is critical to assess for signs of ICP (such as altered level of consciousness, papilledema, or hypertension).

Front

A nurse is assessing a patient using the Glasgow Coma Scale (GCS). The patient opens their eyes to painful stimuli, makes incomprehensible sounds when spoken to, and moves their right arm in response to a painful stimulus but does not move the left side of their body. What is the patient's GCS score?

Back

8

Answer explanation

The Glasgow Coma Scale (GCS) consists of three components: Eye Opening (E), Verbal Response (V), and Motor Response (M).

• Eye Opening (E): The patient opens their eyes to painful stimuli, which scores a 2.

• Verbal Response (V): The patient makes incomprehensible sounds, which scores a 2.

• Motor Response (M): The patient moves their right arm in response to pain but does not move the left side, indicating localization to pain on one side, which scores a 4 (because the patient can localize the pain on the right side).