2/2 Flashcards
What medication should the nurse anticipate giving to a client who was just admitted with an acute exacerbation of MS?
A. interferons IV
B. methylprednisolone IV
C. prednisone PO
D. acetaminophen PO
Answer: B
Rationale: anytime brought in with acute exacerbation - high dose steroids to push back inflammation in immune sys; methylprednisolone
Can use IV interferons - just for prevention; keep on steady basis
Prednisone PO - use when not on ACUTE exacerbation; go after IV to taper off steroids: taper steroids to prevent rebound that could happen
Acetaminophen PO - not primary treatment of MS
What is a manifestation of Guillain-Barre?
A. spasticity
B. no feeling in paralyzed extremities
C. ascending paralysis
D. genetic predisposition
Answer: C
Rationale: ground up; go up to head and recede back down; thinking about AB and O2 transport - what affected first is breathing - prudent nurse understand what oxygen transport device necessary for client experiencing symptoms: nasal cannula/non-breathrer/bi-pap/intubate; want to do less invasive - bi-pap; not an issue with airway but issue with breathing - place on bi-pap first; when lose airway then intubate; do supportive measures that go with it; neurological issues overall - #1 issue besides brain swelling or going into foramen magnum - the #1 issue with most neuro pts - loss of airway
Airway, swallowing, choking - big deals
Hit lungs - on bi-pap help breathe for them - negative and positive pressures and pass gas
Spasticity - no spasticity in GB; flacid paralysis; motor paralysis - PAIN big deal for these guys - destroyed, sensory neurons still working and feeling in that - afferent pathways affected and efferent not effected; cannot move - no offloading
No feeling in paralyzed extremities - LOTS OF PAIN
Genetic predisposition - not genetically predisposed
Fully conscious and aware but not able do anything about it
Which of the following are NOT recommended in seizure precautions?
A. protect client’s head
B. loosen constrictive clothing
C. remove pillows
D. place a tongue depressor in client’s mouth
Answer: D
Rationale: do not put anything in client’s mouth - bite through anything, swallow it and obstruct airway; one exception suction: suction yankauer catheter - not past teeth - only as emergent procedure in buccal mucosa
Loosen constrictive clothing - #1; hanging pat from gown bad idea
Having seizure: Gown away from neck
If not flailing around bed or digging face into pillow: make sure pt safe; what pt doing and how keep safe; stay with them; not constricted; if can and equipment - pad side rails ASAP; head in pillow - get pillow out
Look for when seizing: amount time, how present seizure (say something before hand), later ask if had aura (something seen, smelt, heard before seizure), how long post-ictal period (any length of time - how long until back to baseline) - when in post-ictal period have stay with them
Would you also want to know what type of seizure it is?
A client has HTN, a distended bladder, and perfuse sweating. Which of the following would the SCI be suffering from?
A. autonomic dysreflexia
B. primary injury
C. secondary injury
D. transient concussion
Answer: A
Rationale: not hx of but rn has HTN: 190/110 BP, distended bladder, perfuse sweating; occurs after SCI has healed; see on med-surg unit; something have pay attention to in fact if have foley - twisted - urine not draining; look at skin - pressure points - cause dysreflexic injury; constipated impaction - look for this as well
Client: C6 injury and foley and sudden high BP through roof; tell not feel good; lot perfuse sweating; immediately: palpate bladder FIRST and look tubing; then look at skin; think if impacted; take whatever offensive
Removed offensive component and sat them up - everything else gone away but still have high BP and headache; give an antihypertensive - BP normally not come down without medication - ANS: beta blocker (heavier - block beta-adrenergic system - which overreacted to stimulus); the -olol goal
If all not remove offensive issue and just treated BP, bring BP and cover autonomic area because given meds; meds wear off and go right back up and symp come back
This high BP: stroke (really worried about), kidney failure, lot probs
Primary injury: occurs all body sys and some leads to shock; directly injure the head or SC (hitting head); causes subluxation of SC or brain bruise or hematoma; because of inflammation is a secondary injury as well; traumatic event; is the communication; SC swells and cuts off blood supply increasing risk so not able move and risk for paralyzed; triple A repairs - after repair it esp mid/low - looking for development of new paralysis; high doses - drips of steroids to knock back immune sys and inflammation - damaging and depends on how damages communication; refrain from describing permanent until know it after heavy doses steroids and antiinflammatorys - might resolves/not
Secondary injury: occurs all body sys and some leads to shock; lack of nutrients (specifically O2) getting to SC or brain - happened because of primary injury; another injury; worse if not treated or prevented leading to increased ICP and brain death; inflammation - enough injury - lack O2 where tissue now dead; inflammation and lack O2 - secondary; shock states - inability provide nutrients to certain area; not able get oxygenation to brain - brain unhappy - more fluid pushed into brain causing more swelling - then brain can get herniation - foramen magnum - cuts off blood flow to brain stem - get brain death
At what stage should the nurse understand that the client can no longer hide their manifestations of dementia?
A. early
B. progression
C. late
D. terminal
Answer: B
Rationale: stage 2/progression; can slide between the stages; some people have good days; think before taking on vacation; iffy depending on where at; cannot remember if something diff
Put in unfamiliar situation - very confused and ability to cognitively process declines
Late and terminal - bed bound and 100% care; nursing home
Early - very functional; allowed do limited stuff outside house; hide things; think way around lot situations
Want do for Alzheimer pt knowing depend on familiar to survive: consistent routine (BIG ONE); reorient (depends on pt situation) - keep as orientated as possible - preserves for future - not want throw over edge of agitation - choose battles - best for pt at that time; keep oriented and exercised and avoid restraints - see if going to hurt self - lot monitoring and orders renewed q4hrs - if threat to self or others - full leathers: harm to self or other; soft wrist restraints: pulling out anything
Two entry points: baseball to head; bloodstream - direct and bloodstream
Bacterial
Viral meningitis -
Meningitis
Blood cultures.
Imaging: Computerized tomography (CT) or magnetic resonance imaging (MRI) scans of the head may show swelling or inflammation. X-rays or CT scans of the chest or sinuses may show an infection that may be associated with meningitis.
Spinal tap. A definitive diagnosis of meningitis requires a spinal tap to collect cerebrospinal fluid. In people with meningitis, the fluid often shows a low sugar level along with an increased white blood cell count and increased protein.
BacterialMeningitis
If viral meningitis is suspected, you may need a DNA-based test known as a polymerase chain reaction amplification. Or you may be given a test to check for antibodies against certain viruses to determine the specific cause and proper treatment.
Sepsis is an extreme response to an infection that causes the immune system to release chemicals into the bloodstream that damage your own tissues. If present with meningitis, a bacterial infection is usually to blame. (Viral meningitis does not typically involve the blood and is not associated with sepsis.)
Viral meningitis tends to be less severe than acute bacterial meningitis. Findings include headache, fever, and nuchal rigidity. Diagnosis is by cerebrospinal fluid (CSF) analysis.
Diagnosis of viral meningitis is based on analysis of CSF obtained by lumbar puncture (preceded by neuroimaging if increased intracranial pressure or a mass is suspected). Typically, protein is slightly increased but less than that in acute bacterial meningitis (eg, < 150 mg/dL); however, the protein level can be very high in West Nile virus meningitis. Glucose is usually normal or only slightly lower than normal. Other findings include pleocytosis with a lymphocytic predominance. Nonetheless, no combination of findings in CSF cells, protein, and glucose can rule out bacterial meningitis. Bacterial meningitis is eventually ruled out if no bacteria grow in CSF cultures.
Viral Meningitis
Lot hopelessness - know going to lose motor func ability; still make decisions - esp if want be intubated; side consult to clear to make decisions
ALS
Worried reduced threshold to have a seizure - high temps; hit pt
High temp; high metabolic rate; brain irritated
More blood pushed into brain increasing risk of a seizure
Brain injury
Apply ABC etc; N. diagnosis: #1 if have the expected outcomes: issue with dysphagia - issue with airway and choking
Parkinsons
Pyridostigmin
MG
Bi-pap - maintain own airway - not maintaining airway - need ET tube
GBS
Primary cause - herpes simplex
Treatment: acyclovir
Encephalitis
Benzo used - prefer given IV; rectal 2; seizures - stay on meds; not remove
If not take PO - call doc and diff order for diff route
Unremitting seizure
Status epilecutis
