Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Med Surg2 > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

Normal Intracranial Pressure 🧠

A

5 - 15 mmHg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Increased ICP in the 🧠 can cause

A

⬆️pressure on the 🩸vessels 🪢

causing ⬇️oxygen flow to the 🧠

🚨 Medical 🏥 Emergency 🚨

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Early symptoms of ICP 🧠

A

Low levels of oxygen:
Restlessness 🤼‍♂️
Irritability
Agitation
Altered LOC
Headaches 🤯
Sudden 🤮 w/out nausea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Late symptoms of ⬆️ ICP

A

Nuchal rigidity
Fixed & dilated pupils 👀
Babinski reflex
Abnormal posturing
(Decerebrate- out)
(Decorticate- toward the core 🤌🏽)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Cushing’s Triad

A

-Systolic Hypertension (widened pulse pressure)
-Irregular breathing 🫁
-Bradycardia ⬇️🫀

🚨Sit up as high as you can 🚨

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Nursing considerations for ICP 🧠

A

Avoid ⬆️ ICP further
Head of the Bed 30 degrees or ➕
💩softeners to prevent straining
🚫endotracheal suction for >10 sec
Vitals- possible 🤒
Seizure 🫨precautions

Educate 📚to avoid:
Coughing
Sneezing
Blowing their nose 🤧
Bending over at hips

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Medications 💊 for ICP

A

Diuretic:
IV mannitol to ⬇️ ICP
👀watch kidneys

Anti-seizure drugs:
To prevent seizures

Corticosteroids:
To ⬇️ inflammation
Monitor BS🩸& 🦠, 🧂levels

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the 2 types of Stoke?

A

Ischemic Stroke🪨🛑

Hemorrhagic Stroke🩸

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is an Ischemic Stroke?

A

🩸 flow is cut off due to a blockage 🪨🛑, which leads to ischemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the two types of blockages🛑in an Ischemic Stroke?

A

Thrombosis:
🩸clots that forms on the artery wall

Embolism:
🩸clot, air, or fat travels➡️w/in the body & gets suck, blocking 🩸flow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is a Transient Ischemic Attacks (TIA)

A

A mini stroke

A warning ‼️ sign of an impending stroke

No cerebral infarction or ☠️ occurs in a TIA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is a 🩸Hemorrhagic Stroke?

A

The collection of 🩸in the brain that leads to ischemia & ⬆️ ICP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What can a 🩸Hemorrhagic Stroke be caused by?

A

Ruptured artery
Aneurysm (weakening of vessel)
Uncontrolled HTN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Classic symptom of a Hemorrhagic stroke

A

Sudden severe headache 🤯

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Modifiable risk factors for a Stroke

A

HTN 🚨
Atherosclerosis
Anticoagulation therapy
Uncontrolled DM 🍬
Obesity 🫃
Stress
Oral contraceptives
Smoking 🚬

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Non-Modifiable risk factor for Stroke

A

Family 👨‍👩‍👧‍👧 Hx of Stroke
Older age 👵🏽
Male 👨🏼
Black 👴🏾
Hispanic 🇪🇸🇲🇽
Native American 🪶
Asian 🌏

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Diagnostic for a stroke

A

CT (faster) 🩻
MRI later

Always identify the type of stroke BEFORE starting treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Treatments 💊 for Ischemic Stroke

A

Thrombolytic Therapy (TPA)
-ase meds 💊
(alteplase, reteplase, streptikinase)

Must be administered 3-4.5 🕒hours after onset of symptoms

🚨🚫TPA if 🩸disorder, arterial puncture w/in last week, previous hemorrhagic stroke, recent spinal surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Treatment for hemorrhagic stroke

A

Prevent & treat ⬆️ ICP

Seizure precautions 🚨

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Be FAST (Stroke)

A

F- Facial droop
A- Arm Weakness
S- Speech difficulty
T- Time to call 911

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Complications of a Right ➡️sided Stroke

A

Right = Reckless

Impulsive behavior
Rapid movements
Impaired judgment 🧑‍⚖️

Paralysis on the LEFT side of the body

Spatial-perceptual deficits (neglect of limb) 🦵🏻

Negative effects on the opposite side do not always occur

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Complications of Left⬅️ sided Stroke

A

Left = Languages & Math
Aphasia, reading, or reasoning
Depression or anxiety

Receptive aphasia- unable to comprehend speech

Expressive aphasia- able to comprehend speech but unable to communicate back using speech

Paralysis on RIGHT side of body

Negative effects on the opposite side do not always occur

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What can cause ⬆️ ICP?

A

Swelling of 🧠 tissue
Bleeding 🩸
⬆️ CSF 💦
Tumor 🪨
Infection 🦠
Head injury 🏎️⛷️🧗‍♀️🚴🏼

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Ocular signs for ⬆️ ICP

A

Compression of CN 3️⃣

-sluggish or no response to 🔦
-Fixes, unilateral, dilated pupil= 🚨
-blurred vision
-Diplopia = double vision
-Papilledema= swelling of 👁️nerve
-Extraocular movements= quick ↔️

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Types of motor function

A

Localize- move toward pain (🙋🏽‍♀️)
Withdraw- 👋🏼move away from pain
Decorticate posturing (to core 🤌🏽)
Decerbrate posturing (🫷🏽👳🏼‍♀️🫸🏽

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Phenytoin

A

Given after TBI to prevent seizure activity.

🚫give with other 💊
IV tubing should be flushed before & after Phenytoin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Mannitol 🦭💊

A

-A hypertonic solution used to ⬇️ICP, also a diuretic.

-Give undiltuted through filter to 🚫administering of particulates

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Which ABG results would be desirable for a client with ⬆️ICP?

A

PO2 of 97
PCO2 of 35

Reasoning:
PO2 should be maintained close to 100 to promote cerebral oxygenation

PCO2 indicates a low normal level, preventing vasodilation that happens with hypercapnia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What should be given in attempts to ⬇️ICP during Cushings Triad?

A

Hypertonic solution 💦
3% NS

30
Q

What should you do if someone with a spinal injury has ⬆️ICP?

A

Cervical collar
Lay flat

‼️Reverse Trendelenburg‼️

31
Q

Nutritional Balance for ⬆️ICP

A

May have feeding tubes
👀 wound healing
🚫TPN 🩸due to ⬆️ risk of 🦠
May need to ⬆️glucose for injured brain

32
Q

Normal Serum Osmolarity

A

280 - 295

(💦in the 🩸)

33
Q

At what GCS should you intubate?

A

8

34
Q

What is the gold standard monitoring for ICP?

A

Ventriculostomy

Monitor #
Use aseptic technique if accessing drain

Might have orders to remove # of fluid 💦

35
Q

What can be a 🚨 severe outcome of ⬆️ICP?

A

Shifting intracranial structures leading to
🚨Herniation = ☠️🏴‍☠️🪦

36
Q

DAI
(Diffuse Axonal Injury)

A

Nerve damage doesn’t come back

TBI- twisting/rotating of 🧠- nerves damage

37
Q

Epidural hematoma can lead to

A

Emergency 🚨
“Talk🗣️ & die ☠️syndrome”

Pass out, wake up/talk, sudden death

(Arterial bleeds🩸)

38
Q

A subdural hematoma is

A

Venous

Chronic 👵🏽👴🏼 due to atrophy and

Acute (watch for 🩸)

39
Q

With cranial surgeries🔪 or any surgery you should always know?

A

What kind of surgery

For cares:
Skin site
🩸At site
🦠
elevation

40
Q

Aneurism 🩸

A

Out pouching of a blood vessel, that can burst and bleed

You can coil or clip these

41
Q

An hemorrhagic stroke has the chance

A

To re-bleed 🩸again

42
Q

Anticipated treatments and orders for an Ischemic Stroke 🖤

A

CT scan, ASA💊, MRI (takes 30-60 min), Hapatin, Anticoags, BP 💊

43
Q

What is Spinal Shock ⚡️

A

More deficits than the level of injury

44
Q

What is Neurogenic Shock? 😱

A

Lack of communication w/ the PNS and SNS causing vasodilation ⭕️

T6 or ⬆️

45
Q

A pt is monitored following a craniotomy to evacuate a subdural hematoma. Which finding 🚨the RN to an early indication of ⬆️ ICP?

A

Delayed responses and ⬆️ lethargy

46
Q

For a pt who is suspected of having a stroke, what’s the most important piece of info the RN can obtain?

A

Time 🕦at which strike symptoms first appeared

(Last normal)

47
Q

With head injuries try to avoid NG 👃🏽tubes, especially with

A

Facial or skull fractures 💀

48
Q

Risk factors for CVA

A

🚬, obesity 🫃🏻, inactivity 🛋️, 🍾🍻,
HLD 🐖, HTN, DM🍬, Afib, CAD, 🧑‍🧑‍🧒‍🧒Hx, previous TIA, 👵🏽👴🏼, gender, race 👩🏾👨🏽👦🏻👨🏿‍🦱

49
Q

Vasospasm management for hemorrhagic 🩸 stroke

A

Nimodipine 💊

(Ca channel blocker)
⬇️vasospasms

50
Q

Nursing management for strokes

A

Neuro assessments
🫀Tele
🫁
MSK- ROM
Skin- Q2 turns
GI- stress ulcers
Urinary- 💛I/O
Speech- picture board
Sensory- 🔥/🧊
Coping- rehab

51
Q

Manifestations of Neurogenic shock ⚡️

A

⬇️Hypotension
⬇️Bradycardia 🫀
Temp dysregulation

Sx for up to 6wks

52
Q

Manifestations of Spinal Shock

A

Deep tendon & sphincter reflexes

loss of sensation & flaccid paralysis ⬇️level of injury

Last days to weeks 📆

53
Q

Spinal cord injury C1-C7 Nursing cares

A

👀🫁 respiratory status:
Weakened intercostal muscles
Pneumonia 💦
Atelectasis
Incentive spirometer 💨
Chest physiotherapy

Tetraplegia
C4=Paralysis ⬇️ neck
C6= Paralysis ⬇️ shoulders

Temp, vitals 🩺

54
Q

Spinal cord injury T1-T12 Nursing cares

A

Paralysis ⬇️ injury:
Some 🫁 issues
GI & bladder issues
Some movement of shoulders

Neurogenic bowel & bladder:
Bowel program 🚽
Sit up
Dig stim ☝🏽
GU- clamp foley 💛
Intermittent cath

T6⬇️= Tetraplegia (paralysis below chest)

55
Q

Spinal cord injury L1-L5 Nursing cares

A

Paraplegia
Paralysis ⬇️ waist

Self catheterization 💛
=Prone to 🦠

56
Q

Complete SCI

A

Total loss of sensory & motor ⬇️ level of injury

57
Q

Incomplete SCI

A

Some loss of voluntary motor & sensation

5 syndromes:
Brown-sequard
Cauda equina
Central cord
Anterior cord
Conus medullaris

58
Q

Brown-Sequard 🤎

A

Damage to 1/2 spinal cord

penetrating injury

Conta-lateral loss of pain and temp on opposite side of injury 💜

Loss on voluntary motor control on same side of injury 💙

59
Q

Cauda equina

A

Complete loss of sensation in Sattle area 🤠 🍑

Patchy sensation in lower extremities

60
Q

Autonomic Dysreflexia Triggers

A

Spinal injury T6 or ⬆️

Triggered by sustained stimuli @T6 or ⬇️from:
Restrictive 🥋🧦👖
Pressure areas 🍑🦶🏼
Full bladder 💛
Fecal impaction 💩

61
Q

Autonomic Dysreflexia S&S

A

⭕️Vasodilation⬆️:
Flushed face 🧔🏻
⬆️ sweating
⬆️ BP
HA 🤯
Distended neck veins
⬇️ HR

🕳️Vasoconstriction ⬇️ level:
Pale
Cool 😎
No sweating

62
Q

Manifestations of Parkinson’s Disease

A

Chronic & progressive damage ⛏️ to nerves in 🧠

Tremor 👋🏼
Pill rolling 🤌🏽💊
bradykenesia (slow movement)
Hunched, unstable gate🚶🏽
Hallucinations 😵‍💫
Dementia 🤔
Depression

63
Q

Beginning symptoms of Parkinson’s

A

Tremor 👋🏼& Flat effect 😶

64
Q

➡️Later signs of Parkinson’s

A

Speech 🗣️
Dysphagia
BP changes
Gait instability
Weak chewing 🫢

65
Q

Nursing management for Parkinson’s

A

Small frequent meals 🍌
Schedule enough time for meals 🕦
Aspiration precaution 👄
Fall precautions
Good sleep
Promote 🏋🏽‍♀️- ⬇️ muscle rigity & 💩complications
Communication- no board 👋🏼(stand in front of person to read lips)

Promote independence 🤌🏽

66
Q

Lewy Bodies

A

Build up of protein in 🧠

Causes abnormal 🧠 fx and Parkinson’s

67
Q

MS is more common

A

In women 💃🏻

20 - 40 yrs old

Overweight 🤰🏻

Low vitamin D 🌤️

Smoking 🚬 (can cause relapse of MS)

68
Q

Multiple Sclerosis is where

A

The myelin sheaths break down around nerve

69
Q

Early manifestations of MS

A

Vision Changes 👀

❤️💚 color distortion
🚨Blindness in one 👁️

70
Q

Other manifestations of MS

A

Extremity weakness
Balance coordination 🦵🏻
Numbness & tingling 📌
Lhermitte’s sign “MS hug”
(Spasms to intercostal & abd nerves)

71
Q

Rursing management of MS

A

Independence
⬇️Reduce triggers
Manage fatigue 😴 (🚫exacerbation)
🚫🚬
Coping
Manage stress

Meds 💊:
Dizziness
Depression
Pain
Interferon B

No cure‼️

72
Q

Autonomic Dysreflexia is

A

Life threatening 🚨due to:

Status epileptics
MI
Stroke
Death☠️🏴‍☠️🪦

Med Surg2 (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions