Exam 4 Flashcards
Increased Intracranial Pressure signs and symptoms?
N&V, LOC changes, blurred vision, headache
Your patient is ventilated and has sudden anxious episode and is trying to fight the ventilator, Nursing intervention?
Instruct the client to breathe with the ventilator.
Check the O2 saturation (Concern: hypoxia)
Your patient is trying to cough and the secretions are too thick, What are your nursing interventions?
Humidify the air, increase fluids
A patient arrives and you suspect that he has neurogenic shock, what are your immediate nursing interventions?
100% nonrebreather
C-Collar
avoid lactated ringers
monitor vital signs (BP & T)
administer atropine (to increase heart rate.)
What can low platelets and presence of petechia indicate?
Bleeding and not clotting.
Condition: DIC is forming
Concern: organ failure
Vasopressor side effects to be concerned with?
Chest pain, decreased HR, weakened pulses.
Decreased urine output is normal when patient is taking vasopressor
Priority with any shock patient
Airway support à 100% non-rebreather mask oxygen
What signs and symptoms characterize neurogenic shock compared to the other shocks?
Decreased HR, decreased BP
What is the first nursing action when your patient has a fat embolism?
Assess the O2 saturation and put O2 on the patient
What is an outcome of Cooley’s fracture to be looking for?
Decreased cap refill (>3 seconds)
1 thing to do for a meniscus injury?
Apply an immobilizer to the affected knee.
What does prolonged cap refill indicate on your patient?
Compartment syndrome à Notify the HC
Priority assessment of a patient who has had an ORIF?
Patient is at risk for infection -osteomyelitis
Patient has surgery and starts to develop S/S of tachycardia, tachypnea, decreased O2 saturation, and SOB, what are you concerned about?
Pulmonary embolism -100% O2 Nonrebreather mask.
When does acute back pain typically start to improve?
2 weeks or 7-14 days
Patient education for a patient with low back pain?
Firm mattress, bend with the knees, maintain appropriate body weight, no smoking, on side with pillow between knees, no stomach sleeping
What can a patient take to relieve back pain?
NSAIDS
Metastatic bone cancer interventions
Give sustained release long-acting opioids
monitor serum calcium (will be increased)
when turning the patient, hold the leg in place/ immobilize it.
What is the prognosis for metastatic bone cancer?
Not good.
Monitor patient’s psychosocial needs and provide support to patient and family.
Your patient just had surgery and is having difficulty voiding, what is your biggest concern?
Damage to one of the spinal nerves during surgery
Your patient presents with neck pain and numbness and tingling, what would you assess for?
If there is a compromise in the nerve root, or nerve damage
S/S of osteomyelitis
Fever, bone pain.
What are some proper body mechanics for the back?
Bend at waist, lift with knees, do not twist, feet shoulder width apart, items close to them.
An older patient has osteoporosis, what would you see in your patient?
Shortened height, kyphosis (hunchback)
