Deck 3

Question 1

A nurse is planning care for a client who had a stroke and is experiencing dysphagia. Which of the following actions should the nurse include inn the plan? (SATA)

Answer 1

*Have suction equipment available
*Eliminate distractions during mealtime
*Place food on the unaffected side of the client’s mouth
Inform the client to swallow with the neck flexed forward

Question 2

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following actions should the nurse take?

Answer 2

left homonymous hemianopsia - left side of your vision is lost in both eyes- cannot see left side of anything

Place the client’s bedside table on the right side of the bed

Question 3

A nurse is caring for a client who is receiving an IV infusion of alteplase for the management of a suspected ischemic stroke. Which of the following findings is an adverse effect of this medication?

Answer 3

Epistaxis (nose bleed)

Question 4

In the field, (think motor vehicle accident) What are your top three priorities?

Answer 4

Assess Airway
Stabilize cervical spine (neck)
Hemodynamic status - watch for signs of spinal shock that could lead to neurogenic shock (brady and hypotensive)

Question 5

Interventions for neurogenic shock

Answer 5

IV fluids first (0.9NS)
Pressors (levophed) for BP
Have two large bore IVs (fluids and levo each need their own line)
Atropine (for bradycardia)

Question 6

What are catecholamines?

Answer 6

neurotransmitters and hormones from the sympathetic nervous system that help keep up our BP and HR
dopamine, norepinephrine, and adrenaline (epinephrine)

Question 7

What are you at risk for with myelosuppression?

Answer 7

low red cells = anemia
low white cells = infection -sepsis - death
low platelets = bleeding

Question 8

With DKA is your patient going to be hyperkalemic or hypokalemic?

Answer 8

● Initially, they’re going to be HYPERkalemic → metabolic acidosis initially results in hyperkalemia
The acidotic state releases potassium from the intracellular fluid resulting in hyperkalemia. Then you have polyuria, which dumps the K+ therefore resulting in hypokalemia later on
Monitor for arrhythmias

Question 9

What is global aphasia?

Answer 9

Both receptive and expressive
receptive = trouble understanding
expressive = trouble speaking or writing

Question 10

When you have a patient with global aphasia (receptive and expressive) Which interventions should you implement? SATA

Answer 10

Speak slowly to the client
Assist the client to use cards with pictures
Give instructions to the client one step at a time

Question 11

Complications of a TBI (Traumatic Brain Injury)

Answer 11

Increased ICP due to possible arterial epidural hematomas, or venous subdural hematomas
SIADH(damage to pituitary=overexpression of ADH)
brain herniation
hydrocephalus (swelling).

Question 12

What is your intervention if your patient’s ICP is 19?

Answer 12

Notify provider (normal range is 10-15)

Question 13

Your patient’s BP is 272/190 and HR is 38, What is likely happening with this patient?

Answer 13

autonomic dysreflexia

Question 14

Interventions for autonomic dysreflexia

Answer 14

SIT PATIENT UP
IVP hydralazine or Clonodine (BP)
possible atropine (HR)

Question 15

What is the time window to administer TPA for an ischemic stroke?

Answer 15

3-4.5 hours

Question 16

What are the typical interventions for increased ICP / TBI? (SATA)

Answer 16

Sit patient up if possible/raise head of bed
decrease noise level of surroundings
stool softeners (no straining)

Question 17

Clinical Manifestations (S/S) of Sickle Cell

Answer 17

Abdominal pain
guarding abdomen
fever (103)
pale, yellow hard palette (breakdown of RBCs=Release of bilirubin)
pain (vascular occlusions happening all over body)
signs of ischemia in lower extremities
signs of vascular occlusion (ulcers)
**this can sometimes lead to amputations

Question 18

What do you do if your patient’s ICP is 12?

Answer 18

Continue to monitor/document (normal)

Question 19

Interventions for Back surgery that require hardware (laminectomy, discectomy, fusions)

Answer 19

AVOID TORSION (any twisting)
Log roll (with draw sheet)
place hands on shoulder and hip area
give adequate pain/spasm relief (pain meds)
TLSO (thoracic lumbar sacral orthosis) must be used
*advance diet slowly *(gastric motility is slow due to opioids)
stool softeners

Question 20

describe addisonian crisis

Answer 20

body cannot keep up with stressful situation
adrenals fail and cannot produce stress hormones
(lack of cortisol, aldosterone, catecholamines)

Question 21

Manifestations of Addisonian Crisis

Answer 21

cardiac collapse
hypoglycemia - r/t lack of cortisol
hyponatremia - r/t lack of aldosterone
hyperkalemia - r/t hyponatremia
dysrhythmias - r/t imbalance of potassium and sodium
widespread vasodilation (lack of aldosterone)
bradycardia (lack of catecholamines)

Question 22

Adrenal Crisis is also known as…

Answer 22

Adrenal Insufficiency

Question 23

HHNKS (hyperosmolar hyperglycemic nonketotic syndrome) or (HHS)

Answer 23

type 2 diabetes - has some insulin to get some glucose into cells but not enough- when these patients get sick - glucose levels go crazy
HHS pulls fluids out of cells into the vessels and you pee it out (think HHS has a similar mechanism of action as the drug Mannitol)
More dangerous than DKA

Question 24

Clinical findings of HHNKS (HHS)

Answer 24

BG >600 ** significantly worse than DKA
Neuro decline - seizure, coma, death
polydipsia (excessive thirst)
hypotension

Question 25

SLE (systemic lupus erythematosus)

Answer 25

autoimmune
Hypersensitivity 3 reaction
affects many parts of the body, including kidneys
requires lifelong immunosuppressants (steroids)

Question 26

What is the normal range for platelets?

Answer 26

150,000-400,000

Question 27

What happens with leukemia?

Answer 27

Uncontrolled growth (proliferation) of immature (useless) WBCs
These useless WBCs take up space leaving no room for healthy WBCs, platelets, or RBCs - leading to myelosuppression

Question 28

How are clotting disorders diagnosed?

Answer 28

Blood Tests
Fibrinogen
Hemoglobin
PTT/APTT
platelet/thrombocyte count
clotting factors

Question 29

Thrombocytopenia

Answer 29

low platelet count

Question 30

What is loss of sympathetic tone?

Answer 30

synonymous with neurogenic shock (hypotension and Brady)
means the sympathetic nervous system is not working
no catecholamines
causing widespread vasodilation = hypotension
not enough stimulation to SA node = causing bradycardia

Question 31

What is the treatment for neurogenic shock or (loss of sympathetic tone)

Answer 31

IV fluids
Pressor (possibly Levophed) for BP and HR
possibly atropine for HR