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NSG 4100 FINAL EXAM UPDATED WITH COMPLETE SOLUTIONS
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What would require immediate intervention for a patient with TBIs? - ANSWER>>- Dolls eyes (dilation of eyes), fixation of pupils, paralysis of extremity ---> indicate herniation
- When Turing pt head to one side, and if eyes turn into the same direction = bad response
- opposite direction = normal response
Clinical manifestations that require immediate intervention for acute SDH? - ANSWER>>- Coma, increase BP, decreased HR, slow RR
What emergency procedure would be preformed for a patient with a epidural hematoma? - ANSWER>>Burr holes - release blood accumulated in the between the skull and dura bc it can cause neurological deficits and respiratory arrest
what are some causes for head injuries? - ANSWER>>Sports MVCs Men are more at risk
What is the best action for obtaining an informed consent for an emergency craniotomy for a pt brought by EMS? - ANSWER>>transport the victim to the operating room for surgery
what would require immediate intervention for a patient with head trauma? - ANSWER>>- CSF drainage: meningitis infection can occur
- A depressed fracture - require surgery within 24 hrs
- A battle sign (bruising over the mastoid bone)
- Pts who pees ALOT - indicate dilute urine --> DI
- GCS - score <
- Decorticate and Decerebrate posturing
- Changes in pupils
What is a clinical manifestation of a brain herniation/ increased ICP? - ANSWER>>abnormal pupil response - dilate or nonreactive; normal pupil size is 2-4mm
Pt has a brain injury and possible hemorrhage, what needs to be notified to PCP? ANSWER>>-new onset restlessness is a priority -pt is at home, spouse notices pupil response, slurred speech - take them to hospital
what is a nursing intervention for a patient with a closed head injury to decrease ICP? - ANSWER>>- they will have an increased ICP so you want to elevate the HOB in a neutral position to 30 degrees to reduce the pressure.
- do constant neuro checks
- no flexion of neck or hips (it increases abdominal pressure = increased bp = increased ICP)
- no Valsalva maneuvers (stool softeners, high fiber) -when repositioning in bed, exhalation( opens your glottis to prevent Valsalva maneuver) -Normal ICP: 5-15mmHg -interventions control fever -do use dobutamine (Dobutrex) -norepinephrine (Levophed) -drain CSF -fluid restriction
- cellular metabolic demand reduction -use humidified oxygen
Glasco Coma Scale (GCS) question - ANSWER>>a. Use for monitoring changes during the acute phase the first few days after head injury. It does not take place of an in-depth neurologic assessment. b. Eye (4): spontaneous (4), sound (3), pressure (2), none (1) c. Response (5): oriented (5), confused (4), inappropriate words (3), incomprehensible sounds (2), no response (1) d. Motor (6): obeys (6), moves to localized pain (5), flexion withdrawal from pain (4), decorticate (3), decerebrate (2), none (1) e. 15 max, 8 or less = coma, 3 = unresponsive; 5 = brain death
what is cause, cm, tx for AVM/aneurysms? - ANSWER>>a. cause: cocaine use b. cm: severe generalized headache c. tx: reverse anticoagulant is necessary= heparin (protamine sulfate) Warfarin (vitamin k) antihypertensives
what is a common cause for brain abscesses? - ANSWER>>frequent ear or sinus infections
CSF leak increases to 50-100, should this be reported? - ANSWER>>a. if patient reports postnasal drainage or salty taste = call PCP b. Any changes of above 20 mmHg in BP is significant = call PCP c. post craniotomy 3 days, periorbital edema is expected; PaO2 of 72 is Expected d. excess leakage to be reported A patient diagnosed with a tumor of the brain, is about to undergo craniotomy. What complications might the nurse observe? - ANS>a. increased BP needs to be notified b. increasing ICP, swelling bleeding, visual disturbances need to be notified c. hypovolemic shock, fluid and electrolyte disturbances, infection, CSF leak, seizures
d. commonly caused by gliomas
At what age should children receive the meningitis vaccine to prevent bacterial meningitis? - ANSWER>>a. first dose at ages 11 or 12 b. booster dose at 16 years old c. more at risk: first year college students and members of the military d. household members give Rifadin (rifampin) and ciprofloxacin hydrochloride (cipro) and ceftriaxone sodium (Rocephin) e. must initiate meds immediately up to 24 hrs to avoid prophylaxis f. administer fluids along w/ volume expanders g. health promotion and screening must be continued
cryptococcal meningitis - ANSWER>>a. opportunistic infection from a fungal found in soil and excreta of birds from spores inhaled i. affects nervous system in AIDS patients b. cm: (+) Brudzinski's sign, (+) Kernig's sign, nuchal rigidity, neck immobility, photophobia c. NI: seizure precautions, neuro checks, prevention (vaccine: best thing to do) d. meds: penicillin G in combination with cephalosporin IV (30 mins of arrival), Dexamethasone
You are caring for a patient who has had Huntington's for 15 years & is admitted with pneumonia. Which action is a priority? - ANSWER>>a. they are more at prone for infections, so set up bedside humidification b. cm: chorea, cognitive impairment, behavioral features
what is a comfort measure a nurse can do for a patient with encephalitis/craniotomy? -
b. trigger points: anxiety, depression, physical trauma, emotional stress, sleep disorder, viral infection c. cm: pins and needle sensation, difficulty sleeping d. Difficulty sleeping (ask the pt if they have any difficulty sleeping r/t pain)
what are some triggers for multiple sclerosis and myasthenia gravis? - ANSWER>>a. myasthenia gravis: vigorous physical activity, some medications, and high environmental temperature. b. multiple sclerosis:???
What education statement is CORRECT when teaching your patient, with multiple sclerosis, about activity and mobility? - ANSWER>>a. Walking improves gait b. use of assistive devices, walk with feet apart to widen base of support c. watch feet while walking, do gait training, voiding schedule, drinking schedule, enhance communication and manage dysphagia, cognitive functioning enhancement, increase home management, facilitate sexual functioning, and self-care enhancement
what is the course of ALS and what is a critical complication that can occur? - ANSWER>>a. weakness and atrophy of the upper extremities then speech, swallowing, breathing impaired b. sclerosis begins in legs and moves upward c. Assist patient to make decisions regarding life support and desires for life support care: ventilator care, Feeding Tubes, etc d. nutritional support: attempt to take apple sauce
Your client sustained a C4 injury. You would expect all of the following signs and
symptoms: - ANSWER>>A. Loss of bladder & bowel control b. Loss of diaphragm function c. paralysis of arms, hands, torso & legs d. C1-C5: all extremities, bowel/bladder, diaphragm affected; completely dependent e. C5-C6: indpendent with assist f. C7-C8: independent g. C1-C2: breathing affected, completely dependent
A patient with a spinal cord injury is have hypo reflexes, what is a complication of a spinal cord injury and what should you do? - ANSWER>>a. pt is having autonomic dysreflexia - complication of a spinal cord injury b. tx: assess bladder, wrinkle in sheets (fix the cause) i. increase in BP can cause increase in ICP ii. if there is cold air that is bothering the patient, move the patient c. cm: severe pounding headache, paroxysmal hypertension, profuse diaphoresis above spinal level of lesion, nausea, nasal congestion, and bradycardia
how do you prevent complications from Guillain-Barre Syndrome? - ANSWER>>a. DVTs so wear socks during the day to prevent DVTs because of their immobility from the disease process b. turn, cough, deep breath; incentive spirometer, chest physiotherapy c. prevent ileus with IV fluids/ feeds/ TPN (nutrional support) d. bilateral ascending weakness with dyskinesia - this is normal e. hyporeflexia f. paresthesia g. may rise to resp system → resp failure → intubation
(LR, NS); assess for symptoms of fluid overload b. colloids: large-molecule, similar to plasma protein (albumin); assess for allergies
A patient had severe burns to his right hand a few days ago. He states that the gauze feels as if it is stuck to his skin. What is the next appropriate action? - ANSWER>>a. Loosen the gauze & apply moistened gauze to the site.
What are the phases of burn care, emergent/resuscitative? - ANSWER>>-from onset of injury to completion of fluid resuscitation -priorities: fluid resuscitation, foley, prevent shock, pulses, assessment iii. initial survey (ABCDE) iv. shock prevention v. RDS prevention vi. identify and tx concomitant injury vii. wound eval and initial wound care viii. cm: tachycardia, tachypnea, hypovolemia, electrolyte problems, increased potassium so there will need to be cardiac monitor, edema, hematuria, hypothermia, electrolyte problems
Acute/intermediate phase of care - ANSWER>>i. we must concern ourselves w/ restorative and fluid replacement ii. from start of diuresis to near end of wound closure iii. wound care and closure iv. prevention and tx of complications including infection v. nutritional support
Rehabilitation - ANSWER>>i. from major wound closure to return to individuals optimal level of
physical and psychosocial adjustment ii. prevention and tx of scars and contractures, physical occupational and vocational rehabilitation, functional and cosmetic reconstruction, psychosocial counseling
Emergent burn phase assessments - ANSWER>>primary survey (ABCDE) large bore IV/fluids stop burning process
What is autolytic debridement? - ANSWER>>the viable tissues gradually liquefy the fibrils of collagen that holds the eschar in place. Collagen is a protein found in skin, tendon, bone, cartilage, and connective tissue. Should take between weeks to months to heal
What is surgical debridement? - ANSWER>>involves the use of surgical tools to separate tools to separate and remove the eschar
What is chemical debridement? - ANSWER>>i. topical enzymatic agents are available to promote debridement of burn wounds. ii. use heavy metal ointment such as silver sulfadiazine, mafenide acetate and silver nitrate
What is surgical debridement? - ANSWER>>i. Scalpels, forceps, scissors & other instruments to cut dead tissue from the wound.
- projectile vomiting
- hemiplegia
- decorticate
- decerebrate
- flaccidity before death
- loss of brain stem reflexes: pupillary, corneal, gag, and swallowing reflexes are not present (signs of approaching death)
Normal ICP pressure - ANSWER>>5-15 mmHg
Normal CPP - ANSWER>>70-100 mmHg
an ICP >25 indicates? - ANSWER>>worsening if pressure does not return within 5 minutes
a CPP <50mmHg indicates - ANSWER>>No blood glow and irreversible damage
What is the goal for a Craniotomy post op? - ANSWER>>- aimed at detecting and reducing cerebral edema, relieve ing pain, preventing seizures, monitoring ICP, and neurological status
Plan of care post op for a craniotomy? - ANSWER>>- reduce cerebral edema by giving: mannitol, IV dexamethasone, and taper off when discontinuing
- relieve pain and decrease temp with:
- acetaminophen (mild) codeine and morphine - for severe pain prophylactic anticonvulsants: phenytoin and levetiracetam remove the ICP monitor once ICP is controlled and stable
Post-op assessments for craniotomy? - ANSWER>>- Respiratory status ( s/s of hypoxia, RR, pattern and ABGs) Temp (hyperthermia indicates infection; hypothermia during surgery) tx periorbital edema with cold compresses, this can last for 1-2 days
- neurologic: Q15-60min, avoid head rotation, HOB 30 degrees, reposition Q2H, encourage deep breathing and IS use
- Assess foley - output >200ml indicate DI
What are complication of craniotomy? - ANSWER>>- increased ICP
- bleeding from site
- CSF leakage - emergency
- infections - assess with REEDA
- DI
- SIADH
- seizures
What pt are more susceptible to opportunistic variations of meningitis? - ANSWER>>- college students
- Millitary personal
- dense community groups those who have not been vaccinated before tobacco users pt who have upper viral respiratory infections have otitis media pts with immune deficiencies pt with mastoiditis Aseptic meningitis can effect pt with (cancer, HIV, AIDS, weaken immune system
-to tx rigidity- antiparkinsons meds (Levodopa) -to control psychiatric symptoms- fluoxitive, amitriptyline Nursing intervention for pt with Hungtions disease that are at risk for falls?- ANSWER>>- pad sides of bed
- padded heals and elbow protectors
- keep skin clean
- apply emollient cleansing agent and skin lotion PRN
- use soft sheet and bedding
- encourage ambulation w/ assistance
- secure pt if necessary to bed or chair
Nursing intervention for patient with Hungtions disease with impaired nutritional intake - ANSWER>>- administer phenothiazine before meals (calms pt)
- talk to patient before meal time to promote relaxation
- use warming tray to keep food warm
- keep pt as close to upright position and stabilize head while feeding with other hand
- stabilize pt with use of pillows and wedges for support Use long-stem spoon and place in middle of tongue and exert slight pressure Bite size food is placed Stews, casseroles and thickened liquids Allow pt to completely swallow before bringing next presentation Provide between meal feeding bc the constant spasticity of the body expels more calories Use slenderized meals Gradually introduce textures and consistence
nursing intervention for patients with Huntington's disease that have swallowing difficulties? - ANSWER>>- apply gentle, deep pressure around pt mouth, rub fingers in circles on pts cheek and then down each side of the pt throat -develop skills in hemlock maneuver
nursing intervention for patient with Huntingtons disease with impaired verbal communication - ANSWER>>- read to pt
- employ feedback and relaxation therapy to decrease stress
- collaborate with speech therapist to develop communication system learn specific pt expression and non-verbal cues do not isolate pt by stopping the communication with them Nursing interventions for pt with Huntington's disease who experience acute confusion and loss of socialization - ANSWER>>- reorient the pt after awakening provide a clock, calendar, wall poster to aid in orientation one-to-one interaction utilize music to relax Medical ID bracelet is worn by the pt Keep PT in the social mainstream recruit and train volunteers for social interaction do not isolate pt by ceasing communication with them
What happen during Myasthenia Gravis - ANSWER>>An autoimmune disorder affecting the myoneural junction that is characterized by varying degrees of Muscle weakness of the voluntary muscle
With myasthenia gravis, pyridostigmine bromide worked if? - ANSWER>>There is improved muscle strength, control of fatigue, and improved ADLs
- Medication must be given on time; delayed administration may exacerbate muscle weakness and make it impossible for pt to take meds orally
What are adverse effects of anticholinergics - ANSWER>>diarrhea, abd cramps, excessive saliva
Other txs for myasthenia gravis - ANSWER>>- immunosuppressive (decreased
education for exercise for multiple sclerosis pts - ANSWER>>- promote progressive resistive exercise are used to strengthen weak muscles
- walking promotes improved gait
- Exercise unaffected muscles to compensate for affected
- Teach patient the use of assistive devices to promote safety and proper use Education to reduce spasticity and contracture for multiple sclerosis patients - ANSWER>>- warm packs may be helpful, but avoid HOT showers
- exposure to extreme cold is avoided (cause increased spasticity) daily exercise to minimize joint contractures with emphasis on hamstrings, gastrocnemius muscles, hip adductors, biceps, wrist, and finger flexors prescribed orthotics a stretch-hold-relax routine swimming and staitionay bicycling, progressive weight bearing
education for activity and rest for multiple sclerosis pts - ANSWER>>- encourage to work and exercise to a point just short of fatigue avoid strenuous physical activity take frequent short rest periods air conditioning environment fall precautions
Nutrition education for patient with multiple sclerosis - ANSWER>>- promote healthy eating and weight reduction
- include family in teaching bc they are often food prepers and selectors
- avoid alcohol and smoking
education pt with multiple sclerosis to prevent falls - ANSWER>>- walk with feet apart to widen the base to support and increase walking stability
- if loss of position instruct pt to watch feet while walking
- gait training with assistive device
- for incoordination and tremors use weighted wrist weights
- pt is trained in transfer and ADLs
expected outcomes for patents with a complete spinal cord injury - ANSWER>>loss of both sensory and voluntary motor communication from brain to peripherally, resulting in paraplegia or tetraplegia
anticipated results for a client with an incomplete spinal cord lesion - ANSWER>>spinal cord can transmit messages to and from the brain
- sensory and motor function below lesion is preserved expected results for client with central cord lesions - ANSWER>>weakness of upper extremities compared to lower
- sensation in upper extremities, bowel and bladder is variable or entirely preserved
expected outcomes for patient with an anterior cord lesion - ANSWER>>- loss of pain, temp, and motor function below level of lesions
- light touch, position, and vibration sensation remain intact
expected outcomes for patient with a lateral cord injury - ANSWER>>ipsilateral paralysis or paresis together with ipsilateral loss of touch, pressure, vibration, and contralateral loss of pain and temp
What is Guillain-Barre syndrome? - ANSWER>>is an autoimmune attack on the peripheral nerve myelin, that results in acute rapid segmental demyelination on peripheral nerves and some cranial nerves, producing ascending weakness with dyskinesia (inability to execute voluntary movements), hyporeflexia, and paresthesias (sensation of numbness tingling, or a "pins and needles" sensation
interventions for pts with Guillain-barre syndrome to maintain respiratory function - ANSWER>>- maximize IS and chest physiotherapy
