exam 2

Question 1

Neuro: Describe the characteristics of Cushing’s Triad

Answer 1

Cushing’s triad refers to a set of signs that are indicative of increased intracranial pressure (ICP), or increased pressure in the brain. Cushing’s triad consists of bradycardia, irregular respirations, and a widened pulse pressure

Question 2

Describe early and late signs of increased intracranial pressure

Answer 2

Early: Restlessness, agitation, change in level of consciousness, mental status change, vomiting without nausea

Late: irregular breathing, seizures, posturing, fixed & dilated pupils, coma, cushing’s triad

Question 3

Neuro: Describe Cheyne Stokes respirations

Answer 3

A respiratory pattern that involves a period of fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all

Cheyne Stokes is a late sign of increased intracranial pressure

Question 4

Neuro: Explain the ICPS acronym for use of a patient with an ICP monitor

Answer 4

ICPS is the acronym used to remember ways to prevent spikes in intracranial pressure

I- immobilize the C-spine

C- keep CO2 low in order to prevent vasodilation

P- keep head of bed 30-45 degrees

S- limit the amount of times you suction, hyperventilate when you do suction, and limit attempt to less than 10 seconds.

Question 5

Neuro: Describe levels of consciousness using the Glascow Coma Scale (GCS)

Answer 5

The higher the score on the GCS, the less severe the impact of an injury.

13-15 = mild

9-12 = moderate

3-8 = severe

A decrease in the GCS score is a priority for reporting to the doctor because it indicates a decrease in level of consciousness

Question 6

Neuro: Describe the use of Mannitol for management of ICP including side effects

Answer 6

Mannitol is an osmotic diuretic that elevates blood plasma osmolality, resulting in enhanced flow of water from tissues, including the brain and cerebrospinal fluid, into interstitial fluid and plasma. However, it can also cause fluid to shift into the interstitial space leading to peripheral edema and if not treated, heart failure

Question 7

Neuro: Describe the rationale for slowly decreasing blood pressure of a hypertensive patient who is recovering from a stroke

Answer 7

Patients who experience a hypertensive stroke should have careful management of their blood pressure so that a pseudo hypotensive state is not induced. This is done by slowly decreasing the systolic pressure over a period of 24-48 hours.

Question 8

Neuro: Describe the goal times for tPA treatment for an embolic stroke

Answer 8

The goal for treating an embolic stroke with tPA are time oriented. Best practice is to start tPA within 4 hours of last known well time and within 60 minutes of arrival at treatment center

Question 9

Neuro: Describe autonomic dysreflexia and the priority actions for treatment

Answer 9

Autonomic dysreflexia is a emergent condition that occurs in people with a spinal cord injury occurring at level T5-T6 who are experiencing a stimulus somewhere below the level of injury. Patients present with a sudden increase in blood pressure, decreased heart rate, anxiety, headache, diaphoresis, and skin flushing above the injury site.

The priority action is to eliminate the source of stimuli and then treat the symptoms caused by the condition.

Common stimuli include a blocked urinary catheter, full bladder, urinary tract infection, fecal impaction, tight clothing, and many other possible stimuli.

Question 10

Neuro: Describe the priority for caring for patients with known seizure disorder

Answer 10

Patient safety is the priority for seizure patients. This includes padded bedrails, bed in lowest position, suction set up, side-lying position

Question 11

Cardiac: Describe the primary causes of decreased cardiac output

Answer 11

Anything that disrupts normal circulating volume causing hypovolemia; and conditions that compromise cardiac muscle function or electrical function.

Question 12

Cardio: Explain why defibrillation takes priority over any other intervention when a patient is in ventricular fibrillation

Answer 12

The greatest risk to the client is death from a lack of cardiac output. Ventricular fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and there is no atrial activity. Defibrillation is essential to resolve ventricular fibrillation promptly and convert the rhythm to restore cardiac output. The nurse should follow defibrillation with cardiopulmonary resuscitation and repeated defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable rhythm.

Question 13

Cardio: Describe the characteristics of Atrial Fibrillation

Answer 13

In A. Fib, there are multiple foci of electrical stimulation in the atria which makes the isometric line of the ECG appear squiggly and without a visible P wave. The QRS complex is present because occasional beats are fully conducted.

Question 14

Describe the process of using a central line for medication delivery or blood draw.

Answer 14

When using a central line, you must use aseptic technique, check that the dressing is pristine and the site is free of signs of infection. Before using the line, scrub the hub for at least 15 seconds, use a 10cc syringe, and change the cap if blood is drawn.

Question 15

Cardiac: Describe Mean Arterial Pressure and how to calculate it

Answer 15

MAP is the average arterial pressure during one cardiac cycle and is an indicator of tissue perfusion. Normal MAP is 70-100 and is calculated by taking SBP (+) 2 (DBP) divided by 3.

Question 16

Cardio: Describe the appearance of ventricular tachycardia

Answer 16

Rate: fast

Rhythm: Regular

P wave: no

QRS: wide and bizarre

T: no

Question 17

Cardio: Describe the characteristics of endocarditis

Answer 17

Endocarditis is an infection on the inner layer of the heart. Often it will manifest as vegetation on the valves. It can be caused bacteria, virus, or fungus. People experience fever, chills, weakness, fatigue, malaise, and anorexia.

Question 18

Cardio: Describe why Amiodarone is the treatment of choice for a patient who converts into ventricular tachycardia but has a pulse

Answer 18

Ventricular tachycardia with a pulse is not defibrillated nor is CPR started. Pacing is not indicated. The rhythm will be treated with antiarrhythmics

Question 19

Lines: Describe a normal assessment of an arterial line

Answer 19

The extremity distal to the arterial line should be warm to the touch and have sensation that is baseline for the patient. The site should be visible without excessive drainage and the surrounding tissue should be soft. Any altered findings should be reported immediately

Question 20

Lines: Describe a normal assessment of an arterial line

Answer 20

The extremity distal to the arterial line should be warm to the touch and have sensation that is baseline for the patient. The site should be visible without excessive drainage and the surrounding tissue should be soft. Any altered findings should be reported immediately

Question 21

Lines: State the concept of the transducer used in arterial line pressure measurement.

Answer 21

The transducer is the part of the arterial line that ensures proper pressure readings through its connection to the closed pressure system. In order for accurate pressures to be seen, the transducer must remain at the phlebostatic axis located at midaxillary, 4th intercostal space of the patient.

Question 22

Cardio: State the arrhythmias that are shockable and describe why defibrillation is the priority action

Answer 22

Ventricular Fibrillation and Pulseless Ventricular Tachycardia

Both of these are incompatible with life because there is virtually no cardiac output due to the left ventricle not squeezing efficiently.

Question 23

Discuss the relationship between cardiac arrhythmias and tissue perfusion

Answer 23

Cardiac arrhythmias can impact cardiac output due to the fast or slow rate or the disrupted electrical conduction

Question 24

Cardiac: Describe the mechanism of action for Adenosine and what it is used for.

Answer 24

Adenosine slows the conduction through the AV and SA nodes, thereby disrupting erratic cardiac electrical activity. It is used in the treatment of SVT that is unresponsive to other methods of conversion. Adenosine must administered with consent from the patient, a physician at the bedside, and defibrillation pads in place.

Question 25

Cardiac: Describe pericarditis with clinical manifestations and complications

Answer 25

Clinical manifestations of pericarditis may include sharp pain in the chest, anxiety, dyspnea, a friction rub, and fever. Complications that should be reported immediately may be cardiac tamponade, low blood pressure, muffled heart sounds.

Question 26

Cardiac: Describe the mechanism of action for Atropine and what is is used for

Answer 26

Atropine increases the sympathetic nervous system drive and depresses the parasympathetic drive thereby increasing the heart rate. Atropine can be used to treat symptomatic bradicardia.

Question 27

CVC: Describe nursing measures to prevent CLABSI (central line associated blood stream infection)

Answer 27

Scrub the hub for at least 15 seconds and allow to dry for 15 seconds before administering medications or drawing blood

Assess site for any sign of warmth, redness, or drainage

Practice excellent hand hygiene

Check the dressing and keep it pristine

Question 28

Art. Line: Describe the purpose of the transducer used with a radial arterial line

Answer 28

when a patient has an arterial line, the transducer should be placed at the phlebostatic axis, which is approximated at the 4th intercostal space and midaxillary line. The purpose of the transducer is to provide an interface between the a.line catheter and the monitor using pressure. A misplaced transducer will not give accurate data for intravascular and intracardiac pressure.

Question 29

CVC: Explain a pneumothorax as a complication of a subclavian central line insertion

Answer 29

The location of a subclavian central line present a high risk for lung puncture during the insertion process. In this instance, the patient would demonstrate diminished breath sounds on the affected side