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Med Surg > ICP > Flashcards

ICP Flashcards

1
Q

If a client has a hemorrhagic stroke in the parietal lobe, which function will be affected?

A

Understanding language

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2
Q

Which of the follow causes a ischemia stroke?

a. ) Trauma
b. ) Aneurysm
c. ) Blockage
d. ) Malformation

A

Blockage

The others are causes of the hemorrhagic stroke

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3
Q

When a client present with signs of a stroke what is the priority?

A

Obtain a CT scan

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4
Q

When a client is having a seizure, what is the priority?

a. ) keep client safe
b. ) hold client down
c. ) insert an oral airway
d. ) obtain VS

A

A - Keep client safe

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5
Q

What med would the nurse expect to admin for the acute onset of seizure?

a. ) Pheyntoin
b. ) Narcan
c. ) Daizepam
d. ) Oxcarbazapine

A

C - Daizepam is priority

Pheyntoin & Oxcarbazapine are maintenece

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6
Q

What diagnostic test helps to diagnose seizure activity in the brain?

a. ) EEG
b. ) MRI
c. ) CT
d. ) Vagal nerve stimulator

A

EEG
MRI & CT r/o other conditions
Vagal nerve stimulator is a surgical insert that interrupts seizure activity

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7
Q

What is the diagnostic for meningitis?

A

Lumbar puncture

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8
Q

Which of these explains severe extension of the head with arching of the back?

a. ) Nuchal rigidity
b. ) Kernig’s sign
c. ) Brudinski’s signs
d. ) Opisthotonos

A

D - Opisthotonos

Indicates meningitis

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9
Q

True/False: Parkinson’s disease is curable

A

False

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10
Q

True/False: Clients with MS has tingling and burning in their extremities

A

True

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11
Q

Which assess finding would indicate that a client with meningitis is worsening?

a. ) Purpura lesions on the body
b. ) Pain to the neck with turning
c. ) Complaints of lights hurting eyes
d. ) Nucal rigidity

A

A - Indicate DIC, body shutting down

Other normal findings of meningitis

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12
Q

Which of the following is a finding associated with MS

a. ) Hypertension
b. ) Steady gait
c. ) Ancle clonus
d. ) Blurred vision

A

D - Blurred vision

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13
Q

What med can the nurse administer to help a hemorrhagic stroke pt. with vasospasm

A

Nimodipine - Ca+ channel blockers

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14
Q

Pt. has a stroke in their frontal lobe. What can the nurse expect to be abnormal due to the location of the stroke?

A

Personality changes
Problem solving problems
Creative changes

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15
Q

Pt. has a stroke in their temporal lobe. What can the nurse expect to be abnormal due to the location of the stroke?

A

Memory problems

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16
Q

Pt. has a stroke in their Brain stem. What can the nurse expect to be abnormal due to the location of the stroke?

A

Basic life functions- autonomic system

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17
Q

Pt. has a stroke in their Parietal lobe. What can the nurse expect to be abnormal due to the location of the stroke

A

Visual changes
Understanding language
Reading probs

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18
Q

Pt. has a stroke in their occipital lobe. What can the nurse expect to be abnormal due to the location of the stroke

A

visual changes

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19
Q

Pt. has a stroke in their cerrebellum. What can the nurse expect to be abnormal due to the location of the stroke

A

Balance probs
Coordination probs
Motor function changes

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20
Q

Cranial nerve 3

A

Oculomotor - eye movement up, down, lateral, opening of eyelid, pupil constriction

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21
Q

Cranial nerve 4

A

Trochlear - Medial and downward medial eye movement

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22
Q

Cranial nerve 6

A

Abducens - Lateral eye movement

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23
Q

When the nurse is assessing cranial nerve 3, 4, 6 what condition does the nurse suspect?

A

Meningitis

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24
Q

Homonymous Hemianopia

A

only see left or right side of vision field can be clinical manifestation of stroke

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25
Q

Homonymous Hemianopia is a manifestation of what condition?

A

Stroke

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26
Q

What scale assesses for stroke?

A

National Institute of Health Stroke Scale (NIHSS)

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27
Q

If a pt. has a 42 on the NIHSS. How is the pt. doing?

A

This is the highest a pt. can score on the scale. This means the pt. is not doing good at all. The higher the number the worse they are

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28
Q

Normal ICP level

A

< 20

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29
Q

Broca’s Area

A

responsible for production of speech

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30
Q

Wernicke’s area

A

Responsible for interpreting speech

31
Q

Priority intervention for a pt. comes into ER with symptoms of a stroke

A

CT scan!

To determine if it is hemorrhagic or ischemic stroke

32
Q

Symptoms of Left side brain damage

A

Slow, cautious behavior
Dysphagia
Broca and Wernicke’s area
Paralyzed right side

33
Q

Symptoms of Right side brain damage

A

Quick, impulsive behavior
Spatial/ perceptual deficits
Memory deficit
Paralyzed left side

34
Q

Patient came into the ER with signs of stroke 7 hours ago. The nurse gets a CT and it is determined that the pt. has a ischemic stroke. The HCP order TPA to defuse the clot. What is the nurse’s action?

A

Question the order. TPA can only be given within 3-4 hours of the pt. showing signs of stroke.

35
Q

What can contraindicate a pt. from receiving TPA

A 
Hemorrhagic stroke
Hx Diabetes or prior stroke
Any surgery w/i 3 months
Severe HTN
Internal bleeding
NIHSS score > 25**
Age > 80
Take anticoagulants regardless of INR
Head trauma
36
Q

You assessed your pt. at 0700 he was norm. At 1200 you assess and he shows signs of stroke. It is determined that it is ischemic. What must the nurse determine before admin TPA?

A

When the symptoms started. If neither the pt. or nurse don’t know when the symptoms started, the nurse cannot admin TPA

37
Q

Because the nurse is hydrating a ischemic stroke pt. what complication can occur and what electrolyte imbalance should the nurse watch?

A

The hydration can cause SIADH and the nurse should watch for hyponatremia

38
Q

Permissive hypertension

A

Will allow BP to be high in ischemic stroke pt. for blood to reach the area of ischemia

39
Q

Complications of ischemic stroke

A

Cytotoxic edema

Hemorrhage

40
Q

Diagnosis tool for seizures

A

EEG

41
Q

Priority intervention during ictal phase of seizures

A

Airway management

42
Q

Therapeutic range for phenytoin

A

10-20 mg/mL

43
Q

What is priority assessment during ictal phase of a seizure

A

Time and length and what type of seizure

44
Q

Vagal nerve stimulator increase what neurotransmitter in the brain?

A

GABA

45
Q

What meds can be given for acute seizure activity

A

Benzos

46
Q

What meds are for maintenance of chronic seizures?

A

Phenytoin

Phenobarbital

47
Q

Main clinical manifestations of Meningitis

A 
Nucal rigidity
Opisthotonos
Brundzinki's Sign
Kernig's Sign
Petechia rash > lead to DIC
48
Q

Nucal rigidity

A

Touch chin to chest and causes pain in neck occurs in meningitis

49
Q

Opisthotonos

A

Spasms of the muscles of the neck that causes back to arch

50
Q

Brundzinki’s Sign

A

Involuntary flexion of the hip when the pt. is lay supine and when neck is flexed

51
Q

Kernig’s Sign

A

Pain in the hamstring when the leg is flexed

52
Q

Diagnosis tool for meningitis

A

Lumbar puncture

53
Q

Meningitis is a ___ ___!

A

Meningitis is a MEDICAL EMERGENCY!

54
Q

What meds are ordered for a pt. with meningitis

A

Broad spectrum antibiotics - able to cross blood brain barrier
Corticosteroids
Pain meds

55
Q

What non pharm intervention can decrease ICP?

A

Increase HOB to above 30 degrees

56
Q

Signs of sepsis

A 
Low BP
Low O2
High HR
High RR
high temp
High BS
High WBC
High Lactic Acid
Low platelets
DIC
57
Q

The nurse’s pt. has meningitis. What precautions can the nurse expect the pt. to be in?

A

Droplet precautions

58
Q

How can the nurse assess increased ICP

A

Assess LOC

59
Q

What labs will the nurse expect in a pt. with meningitis?

A

Increase WBC

Increased proteins

60
Q

What lab assessment must the nurse perform before and after lumbar puncture?

A

BS

61
Q

SE of Pramiprexole and Levadopa/Carbadopa

A

Orthostatic Hypotension

Urinary Frequency

62
Q

Why is a pt. with Parkinson’s prescribed anticholinergics and how does the nurse manage these meds?

A

Suppress tremors and drooling

Nurse admin stool softeners and fluids to manage SE

63
Q

Anticholinergic for Parkinson’s

A

Benzotropine

64
Q

Meds for Multiple Scerolsis

A

Beta Interferons
Immunosuppressants
Corticosteroids
Muscle relaxers - Baclofen

65
Q

True/False: There is a cure for MS

A

False, no cure

66
Q

Primary assessments for a pt. with MS

A

Neuromuscular

Skin integrity

67
Q

Risk factors for MS

A

High temperatures
Exercise
Increased stressors

68
Q

Pt. presents with weakness, tremors, partial vision loss, bladder dysfunction, and slurring of words. What can the nurse suspect will be the diagnosis?

A

MS

69
Q

True/False: MRI is the gold standard for diagnosing MS

A

False, there is no specific test that is gold standard. MRI looks at plaques on the brain.

70
Q

What is the goal of Tx for a pt. with MS

A

Recovering form attacks and managing lifestyle and symptoms

71
Q

Teachings for pt. with MS

A 
They are at increased risk for infection (immunosuppressant)
Increase risk for falls
Stay cool
Rest
Eat healthy
Physical therapy - stay mobile
72
Q

What is the priority intervention for a pt. with MS?

A

Maintaining airway

73
Q

What electrolyte imbalance can cause seizures?

A 
Hyponatremia
Hypophosphatemia
Hypomagnesemia
Hyperphosphetemia
Hypernatremia
74
Q

First line meds for seizures?

A

Benzos

Med Surg (22 decks)

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