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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
know what a nurse should do before giving an eternal feeding to a pt
elevate HOB at least 30 degrees
26
if a pt has weakness on the right side and impaired reasoning after having a CVA, what area did the CVA occur in?
left hemisphere of cerebrum
27
know what pt is at greatest for a CVA
Male African American w/ HTN, 51-74 years old, Hx of CVA
28
If a pt experiences a TIA and was prescribed warfarin (Coumadin), what would the effective therapeutic lab values for PT and INR be?
PT: 1.5-2 INR: 2-3
29
know what a nursing teaching plan for a pt with a TIA would include, regarding OTC medications?
daily aspirin dose- thins blood, prevents blood clots
30
a pt recovering from a CVA asks the nurse the purpose of Coumadin, what does the nurse tell the pt?
prevents clot formation (clotting factor)
31
know what the nursing priority is, immediately after a CVA
airway maintenance
32
how does a nurse recognize when the acute phase of a CVA has ended?
Neuro and vital signs stabilize; usually after 24-48hrs
33
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
up to 3hrs from onset
34
know why a lumbar puncture is the most helpful diagnostic tool for a new pt who has had a CVA
to find out if stroke is hemorrhagic or ischemic
35
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?
give medication
36
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
keep side rails up on bed
37
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
forceful coughing
38
know what nursing intervention will help preserve joint mobility in the acute phase of a CVA
support affected legs
39
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?
8mL/hr 400/5000 x 100
40
how does a nurse on assessment know that a pt with CVA in transition to the rehabilitation phase?
no further deterioration of neuro deficits
41
know what "Homonymous Hemianopsia" is and how the nurse should arrange the pts environment, if the pt had a CVA
1/2 field of vision is lost | -arrange items on affected side to strengthen vision
42
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?
to maintain body weight
43
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
learning/ relearning new skills is hard, how do we fix the problem?
44
know what the post hospital option would be, that would provide the most comprehensive assistance to a pt who is recovering from a CVA
rehab center (they have the "whole team")
45
know why "hyperglycemia" can occur in a pt after a stroke (who is not a diabetic). what is this in response to?
increased stress
46
know what level the spinal cord extends to, from the brainstem
2nd lumbar vertebra
47
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?
too early to tell- spinal shock from swelling
48
what nursing assessment would indicate resolution of spinal shock?
is marked by spastic involuntary movements of affected extremities
49
what nursing assessment in the ER would show that a pts SCI (spinal cord injury) is below C4?
unlabored respirations- b/c of phrenic nerve
50
inability of a pt to dorsiflex his/her foot against the resistance of a nurses hand, confirms cord damage at what level?
L5
51
how does a nurse move the impaired leg of a pt with an SCI, to avoid stimulating muscle spasms
passive movement - support knee and ankle
52
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?
muscle move when supported
53
what technique should a nurse use when opening the airway in a newly admitted pt with SCI?
jaw trust
54
know which neurological deficit the "Brown-Sequard" syndrome results in
ipsilateral loss of motor function with contralateral loss of pain and temperature perception
55
know which level of independence is appropriate in a nursing care plan for a pt with C8 transection
upper extremity mobility and manage independent use of W/C
56
if a paraplegic excitedly reports seeing his foot move when he was being turned, how would the nurse explain this phenomenon
reflexive movement
57
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
it will become spastic and spontaneously empty
58
know what the purpose of "Gardner-Wells Tongs" is
Immobilize/ align cervical spine and separate vertebra
59
know what the major advantage pt the halo device over the Gardner-Wells Tongs is
allows Pt to be mobile/ out of bed
60
know why a pt with a SCI would have received the medication methylprednisolone (steroid)
to reduce the damage of cellular membrane -administer within first 8hrs
61
what is autonomic dysreflexia
exaggerated response of the autonomic nervous system to some noxious (painful) stimuli *serious and emergent with SCI
62
know what all of the s/s are of Autonomic Dysreflexia are
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
when a nurse recognizes autonomic dysreflexia in a pt with SCI, what is the immediate nursing intervention?
raise HOB 45 degrees
64
know what nursing interventions are effective in he prevention of autonomic dysreflexia
patency of urinary catheter
65
know how a nurse should respond to SCI pt with a nursing diagnosis of "sexual dysfunction related to altered body function"
address with thoughtfulness and discussion (talk about alt methods)
66
know what rehabilitation does for a pt with SCI
gets them to their maximum level of function and self care
67
know what nursing interventions would be for prevention of contractures in a pt with an SCI
splint extremities
68
if a pts family is concerned with lack of the pts bowel function 2 days after SCI, what would be the nurses best response?
bowel function typically returns after 3 days
69
if a SCI pt has a CAT scan with contrast media, what should the nurse have the pt do after the scan
drink plenty of fluids
70
if a pt sustains a SCI at level C4, will the pt ever be free of a ventilator?
No

Med surg 2 (5 decks)

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