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MedSurg 2 > Eye/ear/neuro > Flashcards

Eye/ear/neuro Flashcards

1
Q

What is astigmatism?

A

irregular or unequal corneal curvature causing the parallel light rays to be bent unequally
Tx is getting the corneal curvature back to normal

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2
Q

what is presbyopia?

A

a form of hyperopia that occurs as a normal process of again usually around age 40 +, not being able to focus on close objects secondary to decreases elasticity. they will try to accommodate by holding written objects further away. tx with bifocals or trifocals because myopia and/or astigmatism can occur at the same time.

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3
Q

What is myopia?

A

nearsightedness. Cant see things far away, an image is formed before it hits the retina.
Causes: excessive light refraction by cornea and lens, abnormally long eye, lens swelling with hyperglycemia, this can increase rapidly during developmental years in growth spurts

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4
Q

what is hyperopia?

A

farsightedness. image is formed before the retina.
Causes: inadequate focusing power, eyeball is too short

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5
Q

what is hordeolum?

A

a sty, infection of the sebaceous gland in the lid margin, usually due to staph areus.

TX: warm moist compress, dont use makeup around the area, lid scrubs (1t baby shampoo + 1 pint warm water) and ABX

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6
Q

What is the difference between LASIK and PRK eye treatments?

A

LASIK: 1 day recovery time, less pain, laser used to remove layer but layer is put back

PRK: 5-7 day recovery time, better for severe myopic problems, more pain, laser is used to completely remove layer

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7
Q

Bacterial conjunctivitis

A

highly contagious
tx: ABX drops, strict hand washing, careful of handling drainage, warm compresses for crustiness

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8
Q

Viral conjunctivitis

A

the sensation of foreign body, self-limiting, usually patients should wait it out but will tx with steroid drops if it persists. If this does not resolve withing 72 hours, go to PCP

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9
Q

Allergic conjunctivitis

A

IGE response, tx by removing cause along with antihistamines, corticosteroids and artificial tears.

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10
Q

bacterial keratitis

A

infection/inflammation of the cornea. mechanical or chemical corneal epithelial damage, usually happens to those who wear contacts. tx with topical ABX, usually 2, if not effective move to a PO/IV abx

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11
Q

viral keratitis

A

viral infection/inflammation of the cornea.

Herpes Simplex:
patients form dendrite ulcers
tx with antiviral eye drops and corneal debridement but NEVER CORTICOSTEROIDS

Varicella Zoster:
Chicken pox
tx with analgesics, topical corticosteroids, mydriatic agents, and topical abx

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12
Q

Cataracts

A

opacity within the lens, age-related, pt complains about glare.
diagnose: with an eye exam with slit lamp microscopy and glare testing
tx:
nonsurgical- increased lens prescription, increased lighting, lifestyle adjustment, and other conservative measures.
surgical- removal/lens replacement

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13
Q

IOP

A

10-21 mmHg

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14
Q

Retinal detachment

A

separation of the sensory retina and the underlying epithelial layer with fluid accumulating between the two, will no longer reflect light in a normal pattern
*Presentation
-While detaching:
Flashes of light
Floaters
Ring in field of vision
-Once Detached:
Painless loss of vision in the area of detachment
-Diagnose with a slit-lamp microscopy and ultrasound of the eye

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15
Q

Tx for increased IOP

A

Beta Adrenergic Blockers: decrease Aqueous humor production

Alpha Adrenergic Agonists: decrease aqueous humor production and improve outflow

Miotics: facilitate aqueous outflow, open trabecular meshwork

Carbonic Anhydrase Inhibitors: decrease aqueous humor production

Make sure to space out drops 5-10 minutes apart to that the drops have time to work before the next one

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16
Q

Age-related macular degeneration

A

retinal degeneration process involving the macula and resulting in degrees of central vision loss.
Dry MD: slow progression and painless vision loss
Wet MD: more severe rapid vision loss with abnormal blood vessels forming around the macula
TX- lasers, injected drugs, and vitamin therapy such as green leafy veggies, vit. C, E, beta-carotene, and Zinc

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17
Q

Glaucoma

A

a condition characterized by increased intraocular pressure which results in optic nerve atrophy and peripheral visual field loss

one of the types is acute angle-closure glaucoma which is an emergency

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18
Q

Acute Angle-closure glaucoma

A

this is an ophthalmic emergency, present with colored halos around lights
tx: laser iridectomy, surgical iridectomy
meds: topical cholinergic agents (miotics)
hyperosmotic agents (mannitol)

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19
Q

external otitis

A

outer ear inflammation/infection. may be bacterial or fungal. symptoms include muffled hearing and discharge.
tx: abx drops, corticosteroid drops, warm moist external compress.
Prevention is key with ear drying drops and ear plugs

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20
Q

otitis media

A

infection/inflammation of the middle ear. complications can be perforated ear drum or meningitis.
tx: PO abx for 10 days

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21
Q

otosclerosis

A

an autosomal dominant disease where the footplate of the stapes is immobilized from spongy bone being developed.
fixed stapes bone=conductive hearing loss
test with Rinne test, bone vs air conduction
tx: hearing aids, vit. D and calcium carbonate, stapedotomy.
Significant hearing improvement right after then it decreases but improves over time.
Nursing care: cotton ball in ear canal, manage n/v, temporary dizziness, avoid bending, lifting, sneezing, coughing, and straining

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22
Q

Meniere’s Disease

A

accumulation of fluid in the inner ear. presents with vertigo attacks, n/v, sweating and pallor, tinnitus, fluctuating sensorineural hearing loss, aural fullness.
ongoing care: diuretics, sedatives, antihistamines, calcium channel blockers. avoid nicotine, caffeine, ETOH, MSG, and have a low sodium diet. Avoid flickering lights and TV during attacks.

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23
Q

hearing loss

A

Conductive: occurs in outer and middle ear and impairs the sound reaching to the ear
Causes:
Impacted cerumen
Foreign body
Perforation of tympanic membrane
Ts: hearing aid
Sensorineural: hearing loss due to impairment of the inner ear or CN VIII-Acoustic nerve
Caused by:
Aging
Ototoxic disease
Immune disease
DM
Cannot be treated with hearing aids
Tx: cochlear implants

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24
Q

Hearing Aids

A

Used for mild to moderate or mild to severe hearing loss
Goal: improved healing through consistent use
Considerations:
Motivation
How much does hearing loss impact lifestyle?
Ability to manipulate small objects
Gradually introduce hearing aid
1: restrict to quiet areas
2: use outside
3: incorporate into other environments
2 Things must be present:
Must be motivated
Must have dexterity

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25
Q

The clinic nurse notes that following several eye examinations, the physician has documented a diagnosis of legal blindness in the client’s chart. The nurse reviews the results of the Snellen’s chart test expecting to note which of the following?

A. 20/20 vision
B. 20/40 vision
C. 20/60 vision
D. 20/200 vision

A

D

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26
Q

The client’s vision is tested with a Snellen chart. The results of the tests are documented as 20/60. The nurse interprets this as:

A. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet.
B. The client is legally blind.
C. The client’s vision is normal.
D. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.

A

D

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27
Q

Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse analyzes the test results as documented in the client’s chart and understands that normal intraocular pressure is:

A. 2-7 mmHg
B. 10-21 mmHg
C. 22-30 mmHg
D. 31-35 mmHg

A

B

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28
Q

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is:

A. Eye pain
B. Floating spots
C. Blurred vision
D. Diplopia

A

C

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29
Q

Cataract surgery results in aphakia. Which of the following statements best describes this term?

A. Absence of the lens.
B. A “keyhole” pupil.
C. Loss of accommodation.
D. Retinal detachment.

A

A

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30
Q

When developing a teaching session on glaucoma for the community, which of the following statements would the nurse stress?

A. Glaucoma is easily corrected with eyeglasses.
B. White and Asian individuals are at the highest risk for glaucoma.
C. Yearly screening for people ages 20-40 years is recommended.
D. Glaucoma can be painless and vision may be lost before the person is aware of a problem.

A

D

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31
Q

For a client having an episode of acute narrow-angle glaucoma, a nurse expects to give which of the following medications?

A. Timolol
B. Atropine
C. Furosemide (Lasix)
D. Urokinase (Abbokinase)

A

A
Betal blockers
Alpha blockers
Miotics
Carbinc anhydrase inhibitors

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32
Q

Which of the following symptoms would occur in a client with a detached retina?

A. Flashing lights and floaters
B. Homonymous hemianopia
C. Loss of central vision
D. Ptosis

A

A

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33
Q

The nurse is caring for a client that is hearing impaired. Which of the following approaches will facilitate communication?

A. Speak frequently.
B. Speak loudly.
C. Speak directly into the impaired ear.
D. Speak in a normal tone.

A

D. You want to speak directly facing the client, in a clear concise voice, do not yell

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34
Q

The nurse has conducted discharge teaching for a client who had a fenestration procedure for the treatment of otosclerosis. Which of the following, if stated by the client, would indicate that teaching was effective?

A. “I should drink liquids through a straw for the next 2-3 weeks.”
B. “It’s ok to take a shower and wash my hair.”
C. “I will take stool softeners as prescribed by my doctor.”
D. “I can resume my tennis lessons starting next week.”

A

C

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35
Q

Your patient has been diagnosed with Macular Degeneration. What foods would you expect her to incorporate into her diet?
Kale
Apples
Nuts
OrangAes
Carrots
Red meat
Kiwi

A

A, C, D, E
A.green leafy veggie
C. Source of zinc
D. vitamin C
E. beta carotene

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36
Q

A client with Meniere’s disease is experiencing severe vertigo. Which instruction would the nurse give to the client to assist in controlling vertigo?

A. Increase fluid intake to 3000 ml a day.
B. Avoid sudden head movements.
C. Lie still and watch the television.
D. Increase sodium in the diet.

A

B

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37
Q

The nurse is reviewing the physician’s orders for a client with Meniere’s disease. Which diet will most likely be prescribed?

A. Low-cholesterol diet
B. Low-sodium diet
C. Low-carbohydrate diet
D. Low-fat diet

A

B

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38
Q

A client is diagnosed with a disorder involving the inner ear. Which of the following is the most common client complaint associated with a disorder in this part of the ear?

A. Hearing loss
B. Pruritus
C. Tinnitus
D. Burning of the ear

A

C

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39
Q

frontal lobe

A

judgement, personality, inhibition
Dysfunction: no filter, expressive aphasia (broca), poor judgement, etc

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40
Q

Temporal Lobe

A

memory and sound, understanding of language
Dysfunction: receptive aphasia (wernicke), memory and speech issues

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41
Q

Parietal Lobe

A

sensory, space analytics, spatial awareness
Dysfunction: decreased/loss of sensations

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42
Q

Occipital Lobe

A

visual perception
Dysfunction: irregular vision

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43
Q

Multiple Sclerosis: Signs/Symptoms

A

Motor:
Weakness to paralysis
Muscle spasticity
Sensory:
numbness/tingling
Partial blindness/blurred vision
Decreased hearing
Cerebellar:
Nystagmus
Dysphagia
Ataxia
Others:
Fatigue
bowel/bladder changes
Sexual disturbances
+ Lhermitte’s Sign
Flex neck to chest, will have shocking sensation down spinal cord
Symptoms decrease during pregnancy but during postpartum women are at greater risk for disease exacerbation.

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44
Q

Multiple Sclerosis: Diagnosis

A

No Definitive Diagnostic test
History & Physical
Clinical manifestations
CSF analysis: Increased IgG
Decreased evoked potential response
CT & MRI: sclerotic plaque- vital

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45
Q

Multiple Sclerosis: Treatment

A

NO CURE
Decrease Inflammation: Prednisone and ACTH
Decrease Autoimmune Attack: immunosuppressants, immunomodulators, monoclonal antibodies
Symptom Management: muscle relaxants
Surgery
Avoid Triggers

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46
Q

Multiple Sclerosis: Nursing Care

A

Promote Independence
Manage symptoms
Optimal nutrition
Prevent complications
Help identify and avoid triggers
Provide resources for mental health

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47
Q

Parkinson’s

A

Definition: chronic, progressive neurodegenerative disorder characterized by slowness in the initiation and execution of movement (bradykinesia/akinesia), increased muscle tone (rigidity), tremor at rest, and gait changes
TRAP
T: Tremor
R: Rigidity
A: Akinesia
Postural Instability
Cause: decrease in dopamine producing neurons in the substantia nigra

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48
Q

Parkinson’s: Signs/ Symptoms

A

EARLY:
Slight limp
Slight tremor
Decrease in arm swing
LATE:
Pill rolling
Aggravated by stress
Worse at rest
Rigidity: resistance to passive movement through ROM
Bradykinesia
Stooped shoulders
Masked expression
Shuffling gait
Drooling- aspiration
Slow, monotonous, slurred speech
Little, if any arm swing

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49
Q

Parkinson’s: Treatment

A

MEDS
Levodopa/Carbidopa (Sinemet)
Levodopa: chemical precursor of DA
Carbidopa: prevents breakdown of levodopa before it reaches brain
Dopamine Receptor Agonists (Requip, Mirapex): directly stimulate DA receptors
Dopamine Agonists (Amantadine): Blocks NMDA-type glutamate receptors, increases dopamine release, and blocks dopamine reuptake
SURGERY
Deep brain stimulator

50
Q

Parkinson’s: Nursing Care

A

Promote exercise
Promote Self care
Promote optimal speech
Bowel regimen
Nutrition
Aspiration risk
HOB elevated, sit upright
Maintain body weight
Fall risk
Drooling
Give atropine 1% solution
-If they are in a soft recliner, they will have a harder time getting out. Protein at night and meds in the morning

51
Q

Myasthenia Gravis

A

Definition: autoimmune disease of the neuromuscular junction marked by fluctuating weakness of certain skeletal muscle groups
Antibodies attack ach receptors
decreases the number of Ach receptors available
Weakness increases with muscle use
Thought to be started by viral infection

52
Q

Myasthenia Gravis: Signs/Symptoms

A

Early muscle fatigue that gets better with rest
Muscles affected: eyes, eyelids, chewing, swallowing, speaking, and breathing
Muscle weakness is worse by the end if day
Complications
Aspiration
Respiratory insufficiency
Respiratory infection
Hallmark: muscle weakness becomes worse with activity and better with rest

53
Q

Myasthenia Gravis: Diagnosis

A

Eyelid droop
Tensilon test:
Electrically stimulate hand
EMG shows muscle fatigue
Tensilon is injected
If muscle improves the patient is positive for MG

54
Q

Myasthenia Gravis: Treatment

A

Medications
Anticholinesterase (Pyridostigmine): prolongs the action of ACh and improves impulse transmission at the neuromuscular junction
Peaks 1 hour after give, schedule nutrition/activity accordingly
Corticosteroids: suppress immune response
Immunosuppressants: suppress immune
Plasmapheresis
Removes plasma from blood to remove anti-ach receptor antibodies
Short term benefits
Used before surgery
Used for crisis
Surgery
Removal of thymus gland
Can also give IgG as well

55
Q

Myasthenia Gravis: Nursing Care

A

Respiration precaution: educate about choking risk
Optimal nutrition
Small meals, easy to chew
Thicken liquids
Schedule meals with peak times of meds
Optimal communication
Self esteem

56
Q

Dementia

A

An overarching name for a variety of disorders
Alzheimer’s is the most common form of dementia
Other forms
Vascular: infarcts from fatty plaques
Mixed types
Systemic
Etc
Symptoms
Memory impairment
Aphasia
Lose short term memory, later lose long term memory

57
Q

Alzheimer’s

A

Multifactorial causes believed to be genetics and other factors (cardiovascular health, diabetes, head trauma, environment, abnormal brain proteins, etc)
Characteristics
High concentration of beta-amyloid plaques
Neurofibrillary tangles seen on postmortem exam
Cannot diagnose alzheimer’s until postmortem exam

58
Q

Alzheimer’s: Diagnosis/Treatments/Nursing

A

Diagnosis by exclusion until time of autopsy
Meds
Cholinesterase inhibitors (memory)
Serotonin reuptake inhibitors (depression)
Antipsychotics (behavioral)
Sleeping aids
Nursing
Risk of injury
Coping for patient and family
Self esteem
Self care
Caregiver burden

59
Q

ICP: the hydrostatic force measured in the brain CSF compartment
The 3 components balance each other out to maintain ICP
The Monro-Kellie doctrine states that the 3 components must stay at a relatively constant volume within the closed skull structure. If the volume of any 1 of the 3 components increases within the cranial vault and the volume from another component is displaced, the total intracranial volume will not change.
One thing has to be displaced

ICP: 5-15

A

Intracranial Pressure

60
Q

Increased ICP: Signs/Symptoms

A

Change in LOC
Change in VS
Watch for Cushing’s Triad
Bradycardia with bounding pulse
Systolic HTN with widening pulse pressure
Irregular respiratory pattern
Occular signs (doll eyes)
Ipsilateral: same side as injury
Contralateral: opposite side of injury
Acidotic
Decreased motor function
Headache
Vomiting
greater than 30 is herniation of brain stem

61
Q

Increased ICP: Diagnosis & Treatment

A

CT & MRI
NO lumbar puncture, because it would add to the pressure
Treatment: tx underlying cause
Meds:
Osmotic diuretics (mannitol) redistributes the volume
Corticosteroids (decadron)

62
Q

Increased ICP: Nursing

A

HOB 30 degrees
Maintain airway and oxygenation
Avoid anything that would increase ICP (stimulation)
Nutrition
Monitor skin integrity
Monitor for infection
Dark environment, no tv, no music
Do not cluster care, could be too much for patient, so monitor ICP while caring for patient
Prevent increase intraabdominal pressure (laxatives, cough suppressants if needed)

63
Q

Your patient has Parkinson’s Disease. What precautions should this patient be put on?
Contact
Isolation
Falls
Seizure
Aspiration

A

C+E

64
Q

Myasthenia gravis occurs when antibodies attack the __________ receptors at the neuromuscular junction leading to ____________.

A. metabotropic; muscle weakness
B. acetylcholine; muscle weakness
C. dopaminergic adrenergic; muscle contraction
D. nicotinic adrenergic; muscle contraction

A

B

65
Q

A patient with myasthenia gravis will be eating lunch at 1200. It is now 1000 and the patient is scheduled to take Pyridostigmine. At what time should you administer this medication so the patient will have the maximum benefit of this medication?
A. As soon as possible
B. 1 hour after the patient has eaten (at 1300)
C. 1 hour before the patient eats (at 1100)
D. at 1200 right before the patient eats

A

C. pyridostigmine peaks one hour after given

66
Q

The exact cause of Alzheimer’s disease is not fully understood. However, what two changes in the brain are found in a patient with this disease? Select all that apply:
A. Destruction of the myelin sheath on the neuron
B. Development of beta-amyloid plaques in between neurons
C. Destruction of dopaminergic neurons
D. Creation of neurofibrillary tangles within the neuron

A

B,D

67
Q

The neurologist is conducting a Tensilon test at the bedside of a patient who is experiencing unexplained muscle weakness, double vision, difficulty breathing, and ptosis. Which findings after the administration of Tensilon would represent the patient has myasthenia gravis?
The patient experiences worsening of the muscle weakness.
The patient experiences wheezing along with facial flushing.
The patient reports a tingling sensation in the eyelids and sudden ringing in the ears.
The patient experiences improved muscle strength.

A

D

68
Q

Which meal option would be the most appropriate for a patient with myasthenia gravis?

A. Roasted potatoes and cubed steak
B. Hamburger with baked fries
C. Clam chowder with mashed potatoes
D. Fresh veggie tray with sliced cheese cubes

A

C. Small meal easy to chew for fatigued muscles

69
Q

During the evening hours you notice your patient with Moderate Alzheimer’s Disease (Middle Stage) begins to experience an increase in confusion, agitations, and hallucinations. What intervention below could the nurse implement to help decrease this occurrence?
A. Provide the patient with coffee at bedtime
B. Provide a relaxing and low noise environment in the evening
C. Use stimulating distractions at night
D. Limit patient’s contact with sunlight during the day

A

B

70
Q

You’re a home health nurse providing care to a patient with myasthenia gravis. Today you plan on helping the patient with bathing and exercising. When would be the best time to visit the patient to help these tasks?

A. Mid-afternoon
B. Morning
C. Evening
D. Before bedtime

A

B they have the most energy in the morning

71
Q

While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe could be dysfunctional?
A. Frontal
B. Occipital
C. Parietal
D. Temporal

A

c

72
Q

To encourage adequate nutritional intake for a female client with Alzheimer’s disease, the nurse should:

A. Stay with the client and encourage him to eat.
B. Help the client fill out his menu.
C. Give the client privacy during meals.
D. Fill out the menu for the client.

A

A

73
Q

The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?

A. Vision changes
B. Absent deep tendon reflexes
C. Tremors at rest
D. Flaccid muscles

A

Diplopia is a neurological symptom that can occur from ms

74
Q

A male patient is having tonic-clonic seizures. What should the nurse do first?

A. Elevate the head of the bed.
B. Restrain the client’s arms and legs.
C. Place a tongue blade in the client’s mouth.
D. Take measures to prevent injury.

A

D

75
Q

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions would the nurse take? Select all that apply.
A. Loosening restrictive clothing.
B. Restraining the client’s limbs.
C. Removing the pillow and raising padded side rails.
D. Positioning the client to the side, if possible, with the head flexed forward.
E. Keeping the curtain around the client and the room door open so that when help arrives, they can quickly enter to assist.

A

A,C,D

76
Q

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?
A. Taking medications as scheduled
B. Eating large, well-balanced meals
C. Doing muscle-strengthening exercises
D. Doing all chores early in the day while less fatigued

A

A
Patients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

77
Q

The nurse is instructing a client with Parkinson’s disease about preventing falls. Which client statement reflects a need for further teaching?
A. “I can sit down to put on my pants and shoes.”
B. “I try to exercise every day and rest when I’m tired.”
C. “My son removed all loose rugs from my bedroom.”
D. “I don’t need to use my walker to get to the bathroom.”

A

D
The patient with Parkinson’s disease would be instructed regarding safety measures in the home. The patient needs to use a walker as support to get to the bathroom because of bradykinesia. The patient would sit down to put on pants and shoes to prevent falling. The patient needs to exercise every day in the morning when energy levels are highest. The client needs to have all loose rugs in the home removed to prevent falling.

78
Q

A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects
a. a severe decrease in cerebral perfusion pressure.
b. an alteration in the production of cerebrospinal fluid.
c. the loss of autoregulatory control of intracranial pressure.
d. a normal balance among brain tissue, blood, and cerebrospinal fluid.

A

D. Normal ICP is 5-15

79
Q

A 5-year-old child arrives at the emergency department, and the child’s parents state that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child’s airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP?
a. Nausea
b. Irritability
c. Headache
d. Bradycardia

A

D (CUSHINGS)

80
Q

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to
a. keep the head of the bed flat.
b. elevate the head of the bed to 30 degrees.
c. maintain patient on the left side with the head supported on a pillow.
d. use a continuous-rotation bed to continuously change patient position.

A

B

81
Q

ICP & CPP

A

Intracranial Pressure (ICP): the hydrostatic force measured in the brain CSF compartment
Normal: 5-15
Cerebral Perfusion Pressure (CPP): the pressure needed to ensure blood flow to the brain
Normal : 60-100
Calculation: MAP-ICP
<30 is incompatible with life: risk for herniation
50 is a critical value
CPP is vital to the brain because the brain does not store oxygen or glucose.. it requires a constant supply

82
Q

Head Trauma: Basal Skull Fracture*

A

Signs/Symptoms
Battle sign: postauricular ecchymosis
Raccoon eyes: periorbital ecchymosis
Fracture is associated with a tear in the dura, this leads to CSF leak (rhinorrhea, otorrhea)
Assessment
Evidence of break of fall
Obtain VS, cross and match blood
Halo sign: clear nasal drainage or drainage from ear: on a gauze, blood will pull to center with yellow surrounding it (evidence of CSF)
Presence of glucose on Tes-tape reading
Ask about antiplatelets meds (aspirin, warfarin, clopidogrel)
Nursing Care
If you see if happen: quickly apply direct pressure or ice to stop bleed
Avoid NG tube**
Fluids/blood

83
Q

Head Trauma: Concussion

A

Definition: a sudden transient mechanical head injury with disruption of neural activity and a change in the LOC
Sudden change in LOC with or without loss of consciousness
Signs/Symptoms
HA
Amnesia to the event
Disruption in level of consciousness
Post Concussion Syndrome
Can develop 2 weeks to 2 months after injury
S/S
Personality changes
Behavioral changes
Decreased attention span
Decreased ability to recall short term memory
Change in intellectual ability
Assessment:
Ask about headache
Ask them to remember 3 words
Count backwards from 100 to 75
Ask about the number of concussions the patient has had
Patient has to be one week headache free to be cleared!

84
Q

Head Trauma: Contusion/Lacerations

A

Contusion: bruising of the brain
Can have a fracture, edema, necrosis at site
Coup-contrecoup: After the head strikes the wall, a coup injury occurs as the brain strikes the skull (primary impact). The contrecoup injury (the second impact) occurs when the brain strikes the skull surface opposite the site of the original impact.
Can have seizure post injury
Lacerations: tearing of brain tissue
Causes bleeding which is very damaging to brain due to the pH of blood
ask ABOUT ANTICOAGULANTS USE

85
Q

Complications of Head Trauma

A

Epidural Hematoma: bleeding between dura and inner surface of the skull
ARTERIAL BLEED—> Neuro Emergency: will need a craniotomy
Hallmark sign: patient loses consciousness, wakes up, rapidly declines!
Subdural Hematoma: bleeding between the dura mater and the arachnoid layer covering the brain
Venous bleed: presents 24-48 hours after the injury is present.
Sometimes can reabsorb itself
Intracerebral bleeding: bleeding within the parenchyma

86
Q

Head Trauma: Nursing Care

A

Get patient to CT to find out what is going on!
Pain management
No narcotics bc it can change the neuro exam
Observe for fever
Neuro Checks
GCS
Pupil Response
Monitor for sensory function
Keep ICP down

87
Q

Ischemic Strokes

A

Thrombotic Stroke: clot forms because of vessel wall injury
Embolic: embolus travels to cerebral artery
d/t secondary issue such as afib (cardiac)
Treatment:
Aspirin
TPA/Fibrinolytic therapy
must be given within 3 to 4 hours of the onset of signs of ischemic stroke
Cerebral angiography (funds tumor)
Merci Retriever (removes clot)
Most important thing we need to know is when symptoms start occuring
What are some questions we need to ask before giving TPA?

88
Q

Hemorrhagic Strokes

A

Intracerebral: bleeding within the brain caused by a rupture of a vessel
HTN is most common cause
Sudden onset of symptoms
Subarachnoid hemorrhage: occurs when there is intracranial bleeding into the cerebrospinal fluid (CSF)–filled space between the arachnoid and pia mater membranes on the surface of the brain
Rupture of cerebral aneurysm
“Worst HA of my life”
Risk for vasospasm
Treatment:
Evacuate bleed
Clip or coil aneurysm
Ligate bleed
Permissive HTN

89
Q

Subarachnoid

A

After a subarachnoid repair, we allow HTN in order to prevent a vasospasm to occur
This allows increased blood flow to cerebral tissue
HHH Therapy to prevent Vasospasm
Hypertension
Hypervolemia
Hemodilution
CCB IV (vasodilates)

90
Q

Strokes: Symptoms

A

Sudden confusion
Sudden difficulty understanding or speaking
Sudden loss of vision out of one eye
Sudden severe headache
Sudden weakness of the face, arm, or leg, especially affecting one side of the body
Warning Signs use: FAST
Face drooping
Arm weakness
Speech difficulties
Time
Communication
Broca’s: expressive aphasia
Wernicke’s: receptive aphasia
Global: expressive and receptive aphasia

91
Q

Stroke Care

A

Time is MONEY
ABC’s!
CT Stat
If ischemic: tpa within 3-4.5 hours
Meds: antiplatelet and anticoagulant if ischemic
OT/PT/Speech
Respiratory and cardiac monitoring
Skin care
BP control
Nutrition
Bowel/Bladder care
Appropriate environment temp and safety

92
Q

Meningitis

A

Acute inflammation of the lining of the brain and spinal cord
Manifestations
Fever
Severe headache
Nuchal rigidity
Photophobia
N/V if bacterial
Viral=Victory
Clear CSF
Bacterial=Bad → Medical Emergency!!
Cloudy CSF

93
Q

Meningitis: Diagnosis

A

Is suspected: Get blood culture and CT scan
Diagnosis is verified by a Lumbar Puncture
Lateral recumbent position
Seated forward
AVOID if ICP is increased
Make sure patient voids before

94
Q

Trigeminal Neuralgia

A

Cranial Nerve 5: Trigeminal
Symptoms:
Sudden pain- knifelike often in lips, cheek, forehead
Twitching, blinking
Precipitates by cold/hot sensation, chewing, brushing teeth
Can be unpredictable pain
Treatment:
Mediation
Tegretol: decreases during of nerve
Surgery
Nursing
Stress management
Total Nutritional Intake**
Self image changes
Monitor for med side effects

95
Q

Bell’s Palsy

A

Definition: Acute, usually temporary, facial paresis (or palsy) resulting from damage or trauma of the facial nerve (CN VII)
Usually affects one side but can affect both
Etiology: unclear, maybe from herpes simplex virus
Diagnostic: by exclusion
Symptoms:
Flaccid face on affected side with drooping mouth and drooling
Unable to close eyelids with an upward movement of eyeball
Flattening of nasolabial folds
Unilateral loss of taste
Decreased ability to chew
Very painful

96
Q

Bell’s Palsy: Nursing Management/Tx

A

Nursing:
Gentle massages, moist heat
Pain management
Aspiration Precaution
Corneal Abrasion risk
Check in with patient for depression/body image
Treatment
Corticosteroids immediately
Acyclovir if HSV is the cause

97
Q

Guillain Barre Syndrome

A

Neurological illness characterized by ascending symmetrical paralysis
Unknown etiology
Characteristics:
1-3 weeks following a URI or GI infection
Distal muscles begin to become weak and spreads up toward the diaphragm
Paresthesia usually followed by paralysis
Complications
Respiratory infection or UTI
Respiratory insufficiency
DVT, paralytic ileus, PE
malnutrition

98
Q

Spinal Cord Injury: Degree

A

Complete: Total loss of motor and sensory below level of injury
Incomplete Cord Lesion: some tracts are spread, so there is partial function restored
Brown Sequard Syndrome**: damage to half of cord.
Contralateral (opposite side of injury): Loss of pain and temperature sensation below level of injury
Ipsilateral (same side as injury): Loss of motor function, light touch, pressure, position, and vibratory sense

99
Q

Spinal Cord Injury: Nursing Care

A

Pain management
Prevent UTI
Prevent respiratory infection
Prevent contractures
Nutrition!
OT/PT
Temperature and safety
Family counseling
Body Image/Self esteem
Autonomic Dysreflexia:
A massive, uncompensated cardiovascular reaction mediated by the SNS
Elevate HOB 45 degrees and determine cause
Most common cause is bladder irritation→immediate catherization

100
Q

Tetanus

A

Severe infection of the nervous system affecting spinal and cranial nerves
Usually from skin wound contaminated with Clostridium tetani (found in soil)
Produces neurotoxin in body that causes tonic muscle spasms
Fever, stiffness in jaw and neck that progresses throughout body
Adults should receive a tetanus q 10 years

101
Q

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the pediatrician’s prescriptions and would contact the pediatrician to question which prescription?
A. Obtain daily weight.
B. Provide clear liquid intake.
C. Nasotracheal suction as needed.
D. Maintain a patent intravenous line.

A

C- no NG tube for basilar skull fracture!!

102
Q

The nurse is reviewing the record of a child with increased intracranial pressure from a head injury and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?
A. Flaccid paralysis of all extremities
B. Adduction of the arms at the shoulders
C. Rigid extension and pronation of the arms and legs
D. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

A

C Decerabate posturing is characterized by the rigid extension and pronation of the arms and leg

103
Q

You have a patient who has recently fell off his skateboard at a skatepark. He has suffered a head laceration. Which of the following will tell you about the neuro status of the patient? Select all that apply
a. Temperature
b. Respirations
c. GCS
d. Pupil reaction
e. HR
f. Heart rhythm

A

c,d

104
Q

Which patient would be a priority patient?
Patient that got hit in the head during a basketball game. Pt complains of HA, brief loss of consciousness
Patient fell while running. Patient has profuse bleeding of the scalp
Patient got in car accident. Loss consciousness at the scene, regained consciousness in EMS ride, is now unresponsive
Patient with a GCS of 13 who came in with shortness of breath

A

C. hallmark of epidural hematoma. MEdical Emergency
What does this patient need?
Craniotomy

105
Q

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?
A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
B. Discuss the precipitating factors that caused the symptoms.
C. Schedule for A STAT computer tomography (CT) scan of the head.
D. Notify the speech pathologist for an emergency consultation.

A

C. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder

106
Q

A patient arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment?
A. Time of onset of current stroke
B. Complete physical and history
C. Current medications
D. Upcoming surgical procedures

A

A

107
Q

What is the expected outcome of thrombolytic drug therapy?
A. Increased vascular permeability
B. Vasoconstriction
C. Dissolved emboli
D. Prevention of hemorrhage

A

C

108
Q

A pt admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?
A. Vomiting continues.
B. Intracranial pressure (ICP) is increased.
C. The client needs mechanical ventilation.
D. Blood is anticipated in the cerebrospinal fluid (CSF).

A

B

109
Q

Which of the following values is considered normal for ICP?
A. 5 to 15 mm Hg
B. 25 mm Hg
C. 35 to 45 mm Hg
D. 120/80 mm Hg

A

A

110
Q

Which of the following signs and symptoms of increased ICP after head trauma would appear first?
A. Bradycardia
B. Large amounts of very dilute urine
C. Restlessness and confusion
D. Widened pulse pressure

A

C

111
Q

The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?

A. Side-lying, with legs pulled up and head bent down onto the chest.
B. Side-lying, with a pillow under the hip.
C. Prone, in a slight Trendelenburg’s position.
D. Prone, with a pillow under the abdomen.

A

A

112
Q

During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute?

A. Limiting conversation with the child.
B. Allowing the child to play in the bathtub.
C. Keeping extraneous noise to a minimum.
D. Performing treatments quickly.

A

C

113
Q

After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?

A. Give him a barbiturate.
B. Place him on mechanical ventilation.
C. Perform a lumbar puncture.
D. Elevate the head of his bed.

A

C. Pt most likely has increased ICP

114
Q

A female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has a history of:

A. Seizures or trauma to the brain.
B. Meningitis during the last five (5 years).
C. Back injury or trauma to the spinal cord.
D. Respiratory or gastrointestinal infection during the previous month.

A

D

115
Q

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help the client cope with this illness?
A. Giving client full control over care decisions and restricting visitors
B. Providing positive feedback and encouraging active range of motion
C. Providing information, giving positive feedback, and encouraging relaxation
D. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

A

C
The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client’s condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

116
Q

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?
A. Fluid is clear and tests negative for glucose.
B Fluid is grossly bloody in appearance and has a pH of 6.
C Fluid clumps together on the dressing and has a pH of 7.
D Fluid separates into concentric rings and tests positive for glucose.

A

D

117
Q

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement?
A. “I will wash my face with cotton pads.”
B. “I’ll have to start chewing on my unaffected side.”
C. “I should rinse my mouth if toothbrushing is painful.”
D. “I’ll try to eat my food either very warm or very cold.”

A

D

118
Q

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.
A. The client is aphasic.
B. The client has weakness on the right side of the body.
C. The client has complete bilateral paralysis of the arms and legs.
D. The client has weakness on the right side of the face and tongue.
E. The client has lost the ability to move the right arm but is able to walk independently.
F. The client has lost the ability to ambulate independently but is able to feed and bathe self without assistance.

A

ABD
Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic, unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

119
Q

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse would bring which most essential items into the client’s room?
A. Nebulizer and pulse oximeter
B. Blood pressure cuff and flashlight
C. Nasal cannula and incentive spirometer
D. Electrocardiographic monitoring electrodes and intubation tray

A

D

120
Q

Which rationale supports the nursing intervention to turn the patient with paraplegia every 1-2 hours
a. To maintain patient comfort
b. To prevent development of pressure injuries
c. To prevent flexion contractures of the extremeties
d. To improve venous circulation in the lower extremeties

A

B

121
Q

Normal Physical Assessment- SATA

A

Visual Acuity 20/20. No diplopia (double vision)
External eye structures symmetric and without lesions or deformities
Lacrimal apparatus non-tender without lesions or deformities
Conjunctiva clear; sclera white
PERRLA
Lens Clear
Optic disc margins sharp
Retinal vessels without AV nicking, with no hemorrhages or spots
Extraocular muscles Intact

MedSurg 2 (1 decks)

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