Assessment Flashcard 2

B. Rationale: The arterial blood gas (ABG) measures the content of oxygen and carbon dioxide dissolved in arterial blood plasma. The value of an ABG is that it can aid in diagnosing metabolic derangements caused by severe illness, such as hypoxemia (low PaO2), hypercarbia (high PaCO2), acidosis (pH < 7.35), and alkalosis (pH > 7.45).

D. Rationale: Respiratory distress can progress into respiratory failure. But sometimes, due to its severity and patients not immediately showing signs and symptoms, respiratory distress can quickly lead to cardiac arrest. Cardiac arrest follows respiratory failure. Shock is a severe condition that can also rapidly progress into cardiac arrest in a critically ill patient if not treated.

D. Rationale: A neurologic examination evaluates brain function. Eliciting the gag reflex, the oculocephalic reflex, and having an equal pupillary response to light stimulation are all indicators of adequate brain function. The Glasgow coma scale is used in conjunction with eliciting these reflexes.

C. Rationale: Assessing disability is part of the primary assessment, and this primarily involves evaluating the patient’s neurologic status. Trauma to the head may induce intracranial bleeding, which results in increased intracranial pressure that can lead to one-sided uncal herniation where the brainstem is compressed. The oculomotor nerve is part of the brainstem, and an ipsilateral uncal herniation can cause uneven or unilaterally dilated pupils in response to light.

A. Rationale: The Glasgow Coma Scale is a neurologic assessment tool. The highest score is 15, and the lowest score is 3. The patient presents with normal neurologic function. Spontaneous eye-opening is scored a 4, obeys command is scored a 6, and oriented and converses is a score of 5 with a total score of 15.

C. Rationale: A child in respiratory distress will present with nasal flaring, retractions, grunting, stridor, or wheezing. Note the positioning of the child. If the child is seated in a tripod position, this is a sign of respiratory distress. Agonal gasp is a sign of cardiac arrest and not increased work of breathing. If agonal gasp is present, prepare to perform CPR. Tachypnea can be due to a physiologic reaction to exercise or fever and does not necessarily represent respiratory distress unless the above signs and symptoms are also present.

C. Rationale: 2-D echocardiography is a noninvasive imaging modality that can assess the anatomic structures of the heart using sound waves. It can evaluate wall motion and the function of heart valves. It also evaluates the movement of blood through the four chambers. Blood within the pericardial sac can restrict heart wall motion. Cardiac tamponade is best assessed by a 2-D echocardiogram in this case.