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)
What would you assess with your patient prior to surgery?
If they are taking any supplements and if they are taking any medication.
Herbs that start with G
What are the problems that would make you prioritize a patient?
Hypotension, airway compromise, bleeding, change in level of consciousness, dizziness, increased temp (>100.4), complaints of severe pain.
Is it normal for a patient to have a low grade temp after surgery?
YES, give analgesic like Tylenol.
A patient returns to the floor after surgery and you see the wound is dehiscence, is this a priority patient?
yes
What lab value would you assess for wound healing?
Albumin (Protein)
Cushing’s triad
Widened pulse pressure, bradycardia, hypertension, respiratory changes
How do you assess CSF fluid?
Nose swab of the drainage-positive for glucose
Treatment for epidural hematoma
Surgery
How do you prevent meningitis?
Vaccinations
Patient presents with intracerebral hemorrhage and unilateral weakness, what should you assess about your patient?
Are they taking any blood thinners?
Your patient has a stroke, and is ordered to have aspirin, when would you hold the patient?
If the patient has a headache, could be pressure from bleeding in the brain.
Aspirin is always contraindicated with bleeding
Nursing actions for a T2 spinal injury
This patient would be a paraplegic.
Urinary catheter
cardiac monitoring
H2 receptor blockers (-tidine, -dine)
monitor for poikilothermia.
Trigeminal neuralgia
Cranial nerve 5
Main reported clinical manifestation is facial discomfort or pain
Bell’s palsy
Cranial nerve 7.
Priority for a patient with a C5 spinal cord injury?
Respiratory, airway
How to limit the development of SIRS
Prevent infection– sepsis
Hand hygiene, remove the urinary catheter as soon as possible, ambulate as soon as possible.
Your patient develops pre-syncope, what are your nursing actions?
fall precautions
Pre-syncope: give something to drink, take VS, call the HCP
What can you delegate to a UAP preop?
VS, CHG bathing, transportation
