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NUR 211 Krissa > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

B.E. F.A.S.T

A

Balance issues
Eye changes
Facial drooping
Arm weakness
Slurred speech
Time to call 911

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2
Q

What do you need to teach family members if their loved one is having a stroke?

A

teach family member to take note of when the symptoms start

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3
Q

What foods to avoid when on anticoag therapy

A

foods high in vitamin K

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4
Q

What do thrombolytics do?

A

dissolve clots; they are clot busters

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5
Q

GI Bleeding
GU Bleeding
Intracranial bleeding
Allergic RXN
BP
Arrhythmias
Ecchymosis
Flushing
N/V
Hemoptysis
Nose/Gums bleeds

are all S/E of what?

A

Thrombolytics

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6
Q

S/E of thrombolytics

A

GI Bleeding
GU bleeding
Intracranial bleeding
Allergic RXN
BP
Arrhythmias
Ecchymosis
Flushing
N/V
Hemoptysis
Nose/gum bleeds

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7
Q

What is the antidote for thrombolytics?

A

Amicar
or
Amnicaproic Acid

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8
Q

Amicar or Amnicaproic Acid is the antidote for what?

A

thrombolytics

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9
Q

What to check before administering thrombolytics

A

weight
PT/INR
PTT
HGB/HCT
plt
CT (what kind of stroke it is. Do not give if hemorrhagic)
order-have a 2 person witness
BP-do not give if BP is uncontrolled

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10
Q

Interventions for Dysphagia and Aspiration

A
  • Implement aspiration precautions
  • Assess gag reflex, if present try sip of water
  • Order speech consult to do swallow study
  • Adhere to prescribe liquid consistency regimen
  • RN should provide initial feeding
  • Educate: sit upright, head forward when swallowing to decrease risk of choking
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11
Q

Interventions for Unilateral neglect

A
  • observe affected side for injury
  • Apply arm sling of a client cannot remember to care for affected arm
  • ensure foot rest is on wheelchair
  • Education: dress affected side first, use unaffected hand to pull affected extremity to midline for protection
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12
Q

Interventions for Constipation

A
  • Assess abdomen for bloating and tenderness
  • Implement bowel training program
  • Administer stool softeners PRN
  • Administer laxatives PRN
  • Education: increase fluid intake (if no swallowing deficits), fiber intake, and movement
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13
Q

Interventions for Urinary Incontinence

A
  • Palpate bladder for distention
  • Anticipate foley catheterization
  • Implement bladder training program
  • Education: Teach kegel exercise, or pelvic muscle exercise
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14
Q

____________ is the main nursing diagnosis for a stroke unless neurological deficits worsen. As patient weakens and LOC decreases ____________ becomes the main priority

A

Ineffective cerebral tissue perfusion
Airway patency

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15
Q

Bladder training interval times

A

Gradually increase time between voiding by 15-min intervals. Start with every 2 hours while awake, then increase as tolerated. At night, go when you feel the need.

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16
Q

modifiable

Risk factors for a stroke

A
  • HTN
  • Atherosclerosis
  • History of DVT
  • Diabetes Mellitus
  • Stress
  • Obesity
  • Cigarette smoking
  • Hypercholesterolemia
  • Oral Contraceptive use
  • Illicit drug use
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17
Q

All of the following are risk factors for what?

  • HTN
  • Atherosclerosis
  • History of DVT
  • Diabetes Mellitus
  • Stress
  • Obesity
  • Cigarette smoking
  • Hypercholesterolemia
  • Oral Contraceptive use
  • Illicit drug use

modifiable

A

a stroke

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18
Q

non-modifiable

risk factors of a stroke

A
  • Age > 55
  • Gender
  • Race: Mexican Americans, Latin Americans, African Americans, Japanese, and Chinese are at higher risk for hemorrhagic stroke
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19
Q

All of the following are risk factors for what?

  • Age > 55
  • Gender
  • Race: Mexican Americans, Latin Americans, African Americans, Japanese, and Chinese
A

A stroke

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20
Q

Left hemisphere stroke assessment findings

A
  • Aphasia; both expressive and receptive
  • Impaired L/R discrimination
  • Agnosia
  • Alexia
  • Agraphia
  • R-sided hemiplegia and hemiparesis
  • Depression, anxiety, quick to become angered or frustrated
  • Hemianopsia

Think Left = Language

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21
Q

Assessment findings for right hemisphere stroke

A
  • Altered perception of deficits (they think they can do more than they can)
  • Unilateral neglect syndrome (ignore left side of the body – they cannot see, feel, or move that side so they are unaware it exists)
  • Loss of depth perception
  • Poor impulse control and judgement
  • Impaired time concepts
  • Left Hemiplegia or hemiparesis
  • Hemianopsia

Think Right = Reckless

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22
Q

All of the following are assessment findings for what?

  • Altered perception of deficits (they think they can do more than they can)
  • Unilateral neglect syndrome (ignore left side of the body – they cannot see, feel, or move that side so they are unaware it exists)
  • Loss of depth perception
  • Poor impulse control and judgement
  • Impaired time concepts
  • Left Hemiplegia or hemiparesis
  • Hemianopsia
A

Right hemisphere stroke

Think right = reckless

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23
Q

All of the following are assessment findings for what?

  • Aphasia; both expressive and receptive
  • Impaired L/R discrimination
  • Agnosia
  • Alexia
  • Agraphia
  • R-sided hemiplegia and hemiparesis
  • Depression, anxiety, quick to become angered or frustrated
  • Hemianopsia
A

Left hemisphere stroke

Think Left = language

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24
Q

If a patient with a hemorrhagic stroke is is experiencing hypotension what needs to be done?

A

HCP needs to be notified ASAP

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25
Q

ACE Inhibitors

Suffix, Example, Action, S/E, NI

A
  • -Pril
  • Enalapril
  • Prevents vasoconstriction
  • S/E: Angioedema, cough, increased K, hypotension
  • NI: Monitor for S/E, K, BP, Pulse
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26
Q

Beta Blockers

Suffix, Example, Action, S/E, NI

A
  • -lol/-olol
  • atenolol
  • Blocks the effect of epinephrine at the receptor site
  • S/E: Bradycardia, dizziness, hypotension, hyperglycemia
  • NI: Do not give to pt with asthma. Monitor glucose, BP, pulse
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27
Q

Calcium Channel Blockers

Suffix, Example, Action, S/E, NI

A
  • -pine, -amil, -zem
  • Amlodipine, cardiazem, verapamil
  • prevents calcium ion movement across cell membranes
  • S/E: orthostatic hypotension, dizziness, bradycardia
  • NI: Monitor BP and pulse, educate pt to change positions slowly
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28
Q

Diuretics

Suffix, Example, Action, S/E, NI

A
  • -semide or -thiazide
  • furosemide, HCTZ
  • Promotes diuresis which in turn promotes NA and fluid loss
  • S/E: Decreased K, NA, and BP
  • NI: Monitor BP, pulse, ECG, electrolytes
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29
Q

What type of medication is this?

  • -lol/-olol
  • atenolol
  • Blocks the effect of epinephrine at the receptor site
  • S/E: Bradycardia, dizziness, hypotension, hyperglycemia
  • NI: Do not give to pt with asthma. Monitor glucose, BP, pulse
A

Beta Blockers

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30
Q

What type of medication is this?

  • -Pril
  • Enalapril
  • Prevents vasoconstriction
  • S/E: Angioedema, cough, increased K, hypotension
  • NI: Monitor for S/E, K, BP, Pulse
A

ACE Inhibitors

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31
Q

What type of medication is this?

  • pine, -amil, -zem
  • Amlodipine, cardiazem, verapamil
  • prevents calcium ion movement across cell membranes
  • S/E: orthostatic hypotension, dizziness, bradycardia
  • NI: Monitor BP and pulse, educate pt to change positions slowly
A

Calcium Channel Blockers

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32
Q

What type of medication is this?

  • -semide or -thiazide
  • furosemide, HCTZ
  • Promotes diuresis which in turn promotes NA and fluid loss
  • S/E: Decreased K, NA, and BP
  • NI: Monitor BP, pulse, ECG, electrolytes
A

Diuretics

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33
Q

Purpose of a CT for stroke patients

A

Used to detect intracranial hemorrhage, space occupying masses, cerebral edema, infarctions, hydrocephalus, cerebral atrophy, and shifts in the brain structures. Should be initial diagnostic test to determine if tPA is needed. Door to CT time is 25 mins, Door to CT results time is 45 mins

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34
Q

Door to CT time

A

25 mins

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35
Q

Door to CT results

A

45 mins

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36
Q

What type of stroke is this?

Occurs d/t plaque build up in the vessel walls, and eventually the blood can not get through. Onset is gradual

A

Ischemic Stroke

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37
Q

What type of stroke is this?

Symptoms gradually worsen as occlusion worsens, usually over a period of several hours to days

A

Thrombolic

type of ischemic stroke

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38
Q

What type of stroke is this?

Instant onset of S/S or instant loss of consciousness

A

Embolic

type of ischemic stroke

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39
Q

What type of stroke is this?

think clot causes vessel to ruptured cerebral aneurysm. Poor prognosis d/t ischemia and increasing ICP; ICP is increasing d/t accumulating blood in the brain. Prognosis can improve by surgery to remove the clot and stop the bleed. Do not use Thrombolytics or Anticoags

A

Hemorrhagic

40
Q

What Lobe is this?

Smell, speech, concentration, planning, problem solving, motor control. Contains Broca’s area.

A

Frontal Lobe

41
Q

What lobe is this?

Touch, pressure, taste, body awareness, language, and reading.

A

Parietal lobe

42
Q

What lobe is this?

Hearing, facial recognition, language, and reading. Also contains Wernicke’s area. Contains Hippocampus which is responsible for learning and memory.

A

Temporal lobe

43
Q

What lobe is this?

Vision, language, and reading

A

Occipital lobe

44
Q

What lobe of the brain controls this?

Coordination

A

Cerebellum

45
Q

either the right or the left side of the brain. Remember it is the clients right or left.

A

Hemisphere

46
Q

pt can understand what is being said but is unable to communicate verbally. Damage occurs in the Broca’s area of the frontal lobe

A

expressive aphasia

47
Q

pt is unable to understand the spoken and often written word. Damage occurs in the Wernicke’s area in the temporal lobe.

A

Receptive aphasia

48
Q

Dysfunction occurs in expression and reception

A

Global Aphasia

49
Q

A stroke symptom

unable to recognize familiar objects

A

Agnosia

50
Q

A stroke symptom

difficulty reading

A

Alexia

51
Q

A stroke symptom

difficulty writing

A

Agraphia

52
Q

A stroke symptom

paralysis

A

Plegia

53
Q

A symptom of a stroke

one-sided paralysis

A

Hemiplegia

54
Q

A stroke symptom

Weakness

A

Paresis

55
Q

A stroke symptom

one-sided weakness

A

Hemiparesis

56
Q

A stroke symptom

loss of half of the field of vision in one eye or both eyes

A

Hemianopsia

57
Q

A stroke symptom

loss of vision in the same half of the visual field of each eye

A

Homonymous Hemianopsia

58
Q

A stroke symptom

The bodys ability to sense it’s location, movements, and actions

A

Propriception

59
Q

A stroke symptoms

Impaired balance or coordination

A

ataxia

60
Q

A stroke symptom

Difficulty swallowing

A

dysphagia

61
Q

A stroke symptom

difficulty or inclear articulation (garbled speech)

A

Dysarthria

62
Q

A stroke symptom

inability to execute skilled movement or gestures despite having the ability and desire to preform them

A

Apraxia

63
Q

What do you need to teach patients who have hemianopsia

A

Turn head from side to side to compensate for the loss of vision

64
Q

LOC

awake with appropriate speech and behavior

A

Conscious

65
Q

LOC

Disorientation, bewilderment, difficulty following commands

A

Confusion

66
Q

LOC

Sleepiness; slow and delayed response to stimulus

A

Lethargic

67
Q

LOC

somnolence with drowsiness between sleep states, lessened interest in the environment, slowed responses to stimulation.

A

Obtundation

68
Q

LOC

minimal movement without stimulus; requires strong vigorous stimulus and then drifts back to unresponsiveness.

A

Stupor

69
Q

LOC

Not arousable

A

Coma

70
Q

What mode of conlifct resolution is this?

  • Unassertive
  • Uncooperative
  • Do not pursue their own needs, goals or concerns
  • Do not assist other to pursue theirs
  • Postpone dealing with issues
A

Avoidance

71
Q

What mode of conflict resolution is this?

  • Neglect their own needs, goals or concerns while trying to satisfy those of others
  • Obeys and serves others
  • Feels resentment and disappointment because they “get nothing in return”
A

Accommodation

72
Q

What mode of conflict resolution is this?

  • Pursue their own needs and goals at the expense of others
  • Stands up for right
  • Defends important principles
A

Competition

73
Q

What mode of conflict resolution is this?

  • Assertive
  • Cooperative
  • Works creatively and openly to find solutions that satisfies most all-important objectives and goals
A

Compromise

74
Q

Action: affects serotonin, norepinephrine and dopamine
Classification: SNRI & DNRI / Antidepressant
S/e:
* Headache
* Dizziness
* Vertigo
* Photosensitivity
* Agitation/tremors
* Insomnia
* Dry mouth/ thirst
* Dehydration
* Constipation

A

Cymbalta (Duloxetine)

75
Q

Nursing interventions for cymbalta

Duloxetine

A

 Monitor BP , appetite and nutritional intake
 Assess sexual dysfunction before taking medication
 Asses for Serotonin syndrome
 Educate family/patient on importance of adherence to medication
 Advise patient to change position slowly d/t orthostatic Hypotension.
 Notify pcp of any attacks , insomnia or worsening depression

76
Q

Action: binds to calcium channel in CNS tissue which regulate neurotransmitter release: does not bind to opioid receptors
Classification: Anticonvulsant, Analgesics
S/E:
* Vertigo
* PR interval prolongation
* Peripheral edema
* Dry mouth
* Abd pain
* Constipation
* N/v/D
* Thrombocytopenia
* Increase appetite
* Increased creatine kinase
* Sucidal ideation
* Angioedema
* Dizziness/drowsiness/headache
* Resp depression

A

Lyrica or Pregablin

77
Q

Side effects of Cymbalta or Duloxetine

A
  • Headache
  • Dizziness
  • Vertigo
  • Photosensitivity
  • Agitation/tremors
  • Insomnia
  • Dry mouth/ thirst
  • Dehydration
  • Constipation
  • Nausea/diarrhea
78
Q

Side effects of Pregabalin

A
  • Vertigo
  • PR interval prolongation
  • Peripheral edema
  • Dry mouth
  • Abd pain
  • Constipation
  • N/v/D
  • Thrombocytopenia
  • Increase appetite
  • Increased creatine kinase
  • Sucidal ideation
  • Angioedema
  • Dizziness/drowsiness/headache
  • Resp depression
79
Q

Nursing interventions of Lyrica or Pregabalin

A

 Monitor closely for note able changes in behavior
 Assess pain location, characteristics, and intensity of pain during therapy
 For seizures assess location , duration and characteristics
 Instruct family to take medication as directed
 Inform pt to report unexplained muscle pain, tenderness weakness.
 Inform pt of weight gain and edema
 Advise patient and family to notify HCP if thoughts of suicide or dying.

80
Q

Action: inhibits mycobacteria’s cell wall synthesis and interferes with metabolism
Classification: Antituberculars
S/e:
* DRESS
* Toxic Epidermal Necrolysis
* Visual disturbances
* Gynecomastia
* Hepatoxicity
* N/V
* Peripheral neuropathy
* Psychosis/ seizures
* Fever
* Bloody dycrasias

A

isoniazid or Isotamine

81
Q

Side effects of Isotamine or Isoniazid

A
  • DRESS
  • Toxic Epidermal Necrolysis
  • Visual disturbances
  • Gynecomastia
  • Hepatoxicity
  • N/V
  • Peripheral neuropathy
  • Psychosis/ seizures
  • Fever
  • Bloody dycrasias
82
Q

Nursing interventions for Isoniazid or isotamine

A

 Importance of medication adherence medication can be continued for 6 mo- 2 yr
 Notify HCP of signs of Hepatitis (yellowing skin or eyes)
 Caution pt to avoid alcohol.
 Hepatic function should be evaluated prior to medication therapy (monthly)
 Importance of regular follow up with pcp and ophthalmologist to monitor for s/e.
 Monitor for symptoms of DRESS
 If Isoniazid overdose occurs, antidote with pyridoxine( Vitamin B)

83
Q

All of the following are S/E of what medication

  • Vertigo
  • PR interval prolongation
  • Peripheral edema
  • Dry mouth
  • Abd pain
  • Constipation
  • N/v/D
  • Thrombocytopenia
  • Increase appetite
  • Increased creatine kinase
  • Sucidal ideation
  • Angioedema
  • Dizziness/drowsiness/headache
  • Resp depression
A

Lyrica or pregabalin

84
Q

All of the following are side effects of what medication

  • Headache
  • Dizziness
  • Vertigo
  • Photosensitivity
  • Agitation/tremors
  • Insomnia
  • Dry mouth/ thirst
  • Dehydration
  • Constipation
  • Nausea/diarrhea
A

Cymbalta of Duloxetine

85
Q

All of the following are s/e of what medication

  • DRESS
  • Toxic Epidermal Necrolysis
  • Visual disturbances
  • Gynecomastia
  • Hepatoxicity
  • N/V
  • Peripheral neuropathy
  • Psychosis/ seizures
  • Fever
  • Bloody dycrasias
A

Isoniazid or isotamine

86
Q

Action: binds to cell receptors enhancing the effects of GABA.
Classification: Benzodiazepine
S/e:
* Drowsiness/sedation
* Lightheadedness/ Dizziness/ Ataxia
* Visual disturbances
* Anger, restlessness
* N/D/ constipation
* Lethargy, Apathy, fatigue
* Dry mouth
* Weight gain
* Physical dependence/psychological dependence/ tolerance

A

Xanax or alprazolam

87
Q

All of the following are side effects of what medication

  • Drowsiness/sedation
  • Lightheadedness/ Dizziness/ Ataxia
  • Visual disturbances
  • Anger, restlessness
  • N/D/ constipation
  • Lethargy, Apathy, fatigue
  • Dry mouth
  • Weight gain
  • Physical dependence/psychological dependence/ tolerance
A

Xanax or alprazolam

88
Q

Nursing interventions for xanax or alprazolam

A

 Inform importance of medication adherence and do not stop abruptly
 Advise pt to avoid grapefruit
 Inform pt the use of other CNS and alcohol can cause resp depression
 Inform pt medication is only for short term use
 May cause drowsiness/dizziness, for older adults inform family how to reduce the risk of falls at home
 May be administer with food if GI is upset
 Assess degree of anxiety and mental status
 Assess for risk of addiction
 Monitor cbc and liver/renal function during therapy
 FLUMAZENIL is antidote if toxicity is noticed

89
Q

Antidote for xanax

A

Flumazenil

90
Q

Flumazenil is the antidote for what?

A

xanax

91
Q

How long can Isoniazid therapy last?

A

6 months to 2 yrs

92
Q

Isoniazid or isotamine antidote

A

Pyridoxine or Vitamin B

93
Q

Pyridoxine or Vitamin B is the antidote for what?

A

Isoniazid or Isotamine

94
Q

7 levels of cognitive ability

A

Knowledge
Understanding
Applying
Analyzing
Synthesizing
Evaluating
Creating

95
Q

7 Levels of cognitive ability

Know You’re Almost Always Saying Everything Correct

KUAASEC

A

K-knowledge
U-understanding
A-applying
A-analyzing
S-synthesizing
E-evaluating
C-creating

NUR 211 Krissa (16 decks)

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