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Med surg 2 > Exam 4 ch 27,28,29 > Flashcards

Exam 4 ch 27,28,29 Flashcards

1
Q

Know what the “Neural Synapse” is

A

The space between the axons of one neuron (in) and the dendrites (out) of the next neuron

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2
Q

Know what an abnormal neurological finding in an 88 year old would be

A

Dizziness and problems w/ balance

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3
Q

know what the most reliable indicator of neurological status would be

A

LOC (level of consciousness)

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4
Q

How would you classify a pt. who is stuporous, but reacts by withdrawing from painful stimuli?

A

semi-comatose

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5
Q

Know what the normal Babinski response would show

A

plantar flexion of toes (curl downward)

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6
Q

know what the nurse should assess on a pt. scheduled for an angiogram

A

allergy to shellfish/iodine

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7
Q

if a severe head injured pt. assumes a posture of flexed upper extremities, with plantar-flexed lower extremities, know what that would indicate

A

increased ICP w/ decorticate posture

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8
Q

when caring for a 90 year old pt. with a closed head injury, know what the nurse would immediately report, related to intracranial pressure

A

HTN

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9
Q

If a pt. with a generalized convulsive disorder has the following nursing diagnosis: “deficient knowledge, related to lack of information about side effects of Dilantin”, what goal and outcome criteria would be most appropriate for the pt?

A

take w/ food to decrease GI upset

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10
Q

know what a positive “Brudinski sign” will show in a pt with meningitis

A

when nurse flexes Pts neck, hip flexion occurs

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11
Q

in assessing a pt. with ICP/ cerebral edema, how would the nurse know that the drug “Mannitol” was effective for the ICP

A

Increased urinary output

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12
Q

know what a nurse would implement for a pt, to prevent a headache after a lumbar puncture

A

have pt lay flat for a specific period of time. encourage oral fluids

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13
Q

know what the 3 classic s/s of “cushing triad” are with ICP

A
  1. Widening pulse/ HTN
    - marked increased systolic w/ no change to diastolic
  2. heart rate initially increases then becomes slow and irregular
  3. bradycardia
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14
Q

in a pt with MS, who had a nursing diagnosis of “knowledge deficit related to conservation of energy”, how would the nurse evaluate a positive outcome to the goal of teaching, with what the pt tells the nurse

A

alternate periods of activity with periods of rest

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15
Q

if a pt fell and hit their head and blacked out for a while, and the nurse suspects an epidural hematoma, what would the nurse be diligent in assessment of?

A

progressive drowsiness

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16
Q

know an intervention related to eating, that should be added to a nursing care plan, to support nutritional intake, in a pt with Parkinson’s disease?

A

thicken liquids to make easier to swallow

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17
Q

if a pt with parkinsons disease states that his current drug regimen of L-dopa and Sinement are no longer controlling the symptoms, what would the nurses best response be

A

other drugs can be combined to L-dopa to increase effectivness

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18
Q

if a parkinsons pt is considering taking “St. John’s Wort”, in addition to Sinemet and L-dopa, what is the best response for the nurse to give the pt

A

can interact and decrease effect of prescription meds

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19
Q

what is Guillain-Barre syndrome?

A

autoimmune disease, usually from a virus or vaccination

  • comes foot to head
  • leaves head to foot
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20
Q

in a pt with “Guillain-Barre” syndrome, who is experiencing impaired breathing patterns, because of neuromuscular failure, what would indicate to the nurse that the pt needs to be suctioned?

A

increased pulse or adventitious breath sounds

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21
Q

if a family member asks the what an appropriate gift for a pt with parkinsons would be, what is the most useful reply?

A

satin sheets

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22
Q

when a pt falls to the floor with generalized seizure, what should the nurse do

A
  • cradle the head or place head on pillow-to prevent injury

- turn pt of side to open airways and prevent aspiration

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23
Q

know what the nuse can to when caring for a pt post craniotomy, to help reduce ICP

A

position HOB (head of bed) 30 degrees

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24
Q

in caring for an unconscious pt. who had a head injury 10 days ago, how should the nurse position the pts limbs

A

prevent flexion, and contractions

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25
Q

know what a nurse should do before giving an eternal feeding to a pt

A

elevate HOB at least 30 degrees

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26
Q

if a pt has weakness on the right side and impaired reasoning after having a CVA, what area did the CVA occur in?

A

left hemisphere of cerebrum

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27
Q

know what pt is at greatest for a CVA

A

Male African American w/ HTN, 51-74 years old, Hx of CVA

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28
Q

If a pt experiences a TIA and was prescribed warfarin (Coumadin), what would the effective therapeutic lab values for PT and INR be?

A

PT: 1.5-2
INR: 2-3

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29
Q

know what a nursing teaching plan for a pt with a TIA would include, regarding OTC medications?

A

daily aspirin dose- thins blood, prevents blood clots

30
Q

a pt recovering from a CVA asks the nurse the purpose of Coumadin, what does the nurse tell the pt?

A

prevents clot formation (clotting factor)

31
Q

know what the nursing priority is, immediately after a CVA

A

airway maintenance

32
Q

how does a nurse recognize when the acute phase of a CVA has ended?

A

Neuro and vital signs stabilize; usually after 24-48hrs

33
Q

in a pt with CVA, several days ago, know how many hours the drug “plasminogen activator (tPA)”, should be used after the onset of symptoms

A

up to 3hrs from onset

34
Q

know why a lumbar puncture is the most helpful diagnostic tool for a new pt who has had a CVA

A

to find out if stroke is hemorrhagic or ischemic

35
Q

in a pt who has suffered a hemorrhagic stroke, is placed on a protocol of 60mg of nimodipine (calcium channel blocker) every 4 hours, if the pts pulse is 82 beats/min, before administration or the medication, what should the nurse do?

A

give medication

36
Q

during the acute phase of CVA, a risk for falls related to paralysis is present, what nursing intervention will best protect the pt from injury

A

keep side rails up on bed

37
Q

since pneumonia is the most frequent cause of death after stroke, what intervention would be contraindicated in the acute care of a pt with a hemorrhagic CVA

A

forceful coughing

38
Q

know what nursing intervention will help preserve joint mobility in the acute phase of a CVA

A

support affected legs

39
Q

a pt in the acute phase of an embolic CVA had the following order: 400 units of heparin per hour IV. the heparin is in a solution of 5000 units/100 mL normal saline. what should the nurse set the electronic IV monitor at? how many mL/hour?

A

8mL/hr

400/5000 x 100

40
Q

how does a nurse on assessment know that a pt with CVA in transition to the rehabilitation phase?

A

no further deterioration of neuro deficits

41
Q

know what “Homonymous Hemianopsia” is and how the nurse should arrange the pts environment, if the pt had a CVA

A

1/2 field of vision is lost

-arrange items on affected side to strengthen vision

42
Q

is a nurse is using the nursing diagnosis: “impaired nutrition, related to dysphagia, with the goal of adequate nutrition” what appropriate outcome criteria would the nurse use?

A

to maintain body weight

43
Q

if a pt is in the rehabilitation phase after a CVA and accidentally knocks an adapted plate from the table and bursts into tears, what would be the nurses best response

A

learning/ relearning new skills is hard, how do we fix the problem?

44
Q

know what the post hospital option would be, that would provide the most comprehensive assistance to a pt who is recovering from a CVA

A

rehab center (they have the “whole team”)

45
Q

know why “hyperglycemia” can occur in a pt after a stroke (who is not a diabetic). what is this in response to?

A

increased stress

46
Q

know what level the spinal cord extends to, from the brainstem

A

2nd lumbar vertebra

47
Q

if a pt sustains a C5 compression fracture and can move only his head and has flaccid paralysis of all extremities, is the paralysis permanent?

A

too early to tell- spinal shock from swelling

48
Q

what nursing assessment would indicate resolution of spinal shock?

A

is marked by spastic involuntary movements of affected extremities

49
Q

what nursing assessment in the ER would show that a pts SCI (spinal cord injury) is below C4?

A

unlabored respirations- b/c of phrenic nerve

50
Q

inability of a pt to dorsiflex his/her foot against the resistance of a nurses hand, confirms cord damage at what level?

A

L5

51
Q

how does a nurse move the impaired leg of a pt with an SCI, to avoid stimulating muscle spasms

A

passive movement - support knee and ankle

52
Q

when recording findings of muscle strength, the nurse records a “2” for the right arm. what does this show for the muscle of the arm?

A

muscle move when supported

53
Q

what technique should a nurse use when opening the airway in a newly admitted pt with SCI?

A

jaw trust

54
Q

know which neurological deficit the “Brown-Sequard” syndrome results in

A

ipsilateral loss of motor function with contralateral loss of pain and temperature perception

55
Q

know which level of independence is appropriate in a nursing care plan for a pt with C8 transection

A

upper extremity mobility and manage independent use of W/C

56
Q

if a paraplegic excitedly reports seeing his foot move when he was being turned, how would the nurse explain this phenomenon

A

reflexive movement

57
Q

after spinal shock resolves and the pts indwelling catheter is removed, what does the nurse tell the pt about how to expect the bladder to empty

A

it will become spastic and spontaneously empty

58
Q

know what the purpose of “Gardner-Wells Tongs” is

A

Immobilize/ align cervical spine and separate vertebra

59
Q

know what the major advantage pt the halo device over the Gardner-Wells Tongs is

A

allows Pt to be mobile/ out of bed

60
Q

know why a pt with a SCI would have received the medication methylprednisolone (steroid)

A

to reduce the damage of cellular membrane -administer within first 8hrs

61
Q

what is autonomic dysreflexia

A

exaggerated response of the autonomic nervous system to some noxious (painful) stimuli
*serious and emergent with SCI

62
Q

know what all of the s/s are of Autonomic Dysreflexia are

A

sudden HTN, pounding H/A, anxiety, flushed face, diaphoresis, nasal congestion, bradycardia, vasoconstriction below lesion with cold “goose skin”, vasodialation above lesion with warm moist skin

63
Q

when a nurse recognizes autonomic dysreflexia in a pt with SCI, what is the immediate nursing intervention?

A

raise HOB 45 degrees

64
Q

know what nursing interventions are effective in he prevention of autonomic dysreflexia

A

patency of urinary catheter

65
Q

know how a nurse should respond to SCI pt with a nursing diagnosis of “sexual dysfunction related to altered body function”

A

address with thoughtfulness and discussion (talk about alt methods)

66
Q

know what rehabilitation does for a pt with SCI

A

gets them to their maximum level of function and self care

67
Q

know what nursing interventions would be for prevention of contractures in a pt with an SCI

A

splint extremities

68
Q

if a pts family is concerned with lack of the pts bowel function 2 days after SCI, what would be the nurses best response?

A

bowel function typically returns after 3 days

69
Q

if a SCI pt has a CAT scan with contrast media, what should the nurse have the pt do after the scan

A

drink plenty of fluids

70
Q

if a pt sustains a SCI at level C4, will the pt ever be free of a ventilator?

A

No

Med surg 2 (5 decks)

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