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NCLEX > module 5 > Flashcards

module 5 Flashcards

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1
Q

neuro assessment 5

A
  1. glasgow coma scale: LOC eye opening, motor response, verbal response
  2. PERRLA
  3. Hand grips- strength and command
  4. babinski reflex abnormal if >1 year old
  5. deep tendon reflexes
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2
Q

ICP s/s

A

S/S:
Early: change in LOC, slowed speech/response, restless,
confusion

Late: Marked change in LOC, vital sign changes,
Cushing’s triad: systolic HTN, widening pulse pressure,
slow bounding pulse, irregular respirations (Cheyne‐
Stokes)

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3
Q

psych depression s/s

tx

A

loss of interest, negative view, anhedonia-loss of pleasure, related to loss
appearance: unkept, weight gain w mild, weight loss w severe, crying, no energy, tired
suicide risk- ask them.
tx: needs accomplishments, no false praise, need activity., need assistance

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4
Q

suicide assessment 5

tx

A
  1. increase risk when medication started
  2. sudden change in mood for the better
  3. increase risk in elderly men and native americans
  4. plan- have one? how lethal?
  5. watch: will writing, isolation, giving away things
    tx: direct closed ended statements, safe environment
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5
Q

hemothorax and pneumothorax a/p
s/s
tx

A

a/p: pleural space should be slammed shut! hemo: blood/fluid. pneumo: air

s/s: SOB, increase hr, diminished breath sounds and movement, chest pain, cough, subc emphysema,
tx: chest tube

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6
Q

thoracentesis

A

pre: consent form, stop anticoags, chest x ray and baseline vs, position: lean over chair or table or lie on unaffected side with HOB 45
post: be still- dont cough, fluid removed from pleural space and lungs re expand, check VS and compare with baseline, watch for FVD and re- xray chest for success

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7
Q

what does a positive babinski mean

A

there is a severe problem in the central nervous system that is affecting an upper motor neuron

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8
Q

ICP early and late signs

A

early: change in LOC, slurred or slow speech, increase drowsiness, confusion, restlessness for no apparent reason
late: LOC progressing to stupor then coma, cushings triad
- systolic HTN with a widening pulse pressure. slow/full bounding pulse, irregular respirations

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9
Q

anytime you have a client with a head injury, if they start complaining of a headache…

A

assume icp is going up

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10
Q

treatment for IICP

A

reducing cerebral edema, reducing volume in the brain
maintain cerebral perfusion for oxygenation
maintain adequate cerebral perfusion- no hypotension because that would decrease brain perfusion
keep temp below 100.4
kep head midline
elevate HOB
nursing interventions should be spaced
HYPERTONIC SOLUTIONS

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11
Q

what diuretic is good to pull fluid off the brain and filter it out through the kidney; decreases ICP

A

mannitol

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12
Q

meningitis
what is it
s/s
tx

A
  • inflammation of the covering of the spinal cord and brain. can be viral or bacterial which is transmitted through the respiratory system
  • chills, high fever, severe headache, nuchal rigidity, disorientation, seizures, positive kernig and brudzinski signs, photophobia
    tx: antibiotics, corticosteroids, analgesics, droplet precaution for bacterial,contact precautions for viral
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13
Q

difference between a closed tbi and a open tbi

A

closed: brain is injured but the skull is not broken, fractured, or penetrate. the dura is not torn
open: brain injury where the skull is broken, fractured, or penetrated. the dura is torn in a penetrating injury.

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14
Q

when to bring patient to ED with concussion

A

difficulty awakening/speaking, confusion, severe headache, vomiting, pulse changes, unequal pupils, on sided weakness; ICP IS GOING UP

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15
Q

autonomic dysreflexia
what is it
s/s
tx

A

upper spinal cord injury (t6) with exaggerated response to certain stimuli that are harmless to someone without a spinal cord injury
s/s: severe HTN, distended bladder or impaction of stimuli, bradycardia, nasal stiffness, flushing, sweating, blurred vision.
tx: sit client up to lower BP, treat the cause, remove any impaction

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16
Q

CT scan

A

takes pictures in layers to allow seeing inside the objects

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17
Q

MRI

A

magnetic use that looks at organs and structures inside the body. examining the brain and spinal cord

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18
Q

pet scan

A

image test to view parts of the brain or any organ as it is working
this is has the colors

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19
Q

cerebralangiography

A

series of timed xrays of the cerebral circulation using dye; images of blood vessels in and around the brain

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20
Q

EEG

A

records electrical brain activity

diagnosis for seizures, sleep disorders, cerebral infarcts; evaluates LOC and dementia, indicator of brain dead

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21
Q

mania
s/s
tx

A

continuous high, flight of ideas, delusions of grandeur and persection, constant motor activity , manipulation and poor judgement
tx: decrease stimuli, dont argue or try to reason, set limits and be consistent, supply finger foods and fluids

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22
Q

ECT

pre and post

A

used for severe depression

pre: NPO, void, atropine to dry up secretions, signed consent
post: position client on side, stay with them, temporary memory loss, reorient them repeatedly, return to day to day activities ASAP

23
Q

schiz
s/s
tx

A

inappropriate affect, flat affect, or blunted affect. looseness of associates, ineffective communication skills (echolalia- repeating words they hear)
(neologism- making up new words), word salad, hallucinations
tx: decrease stimuli, keep conversations reality, observe frequently and observe for hallucinations
let client know you dont share the preception

24
Q

paranoid personality
s/s
tx

A

always suspicious, pathologic jealousy, unemotional, abnormal anger response
tx: be reliable and build trust! consistent nurses and brief visits. always ID meds, sealed foods

25
Q

restraints

A 
orders must be renewed: 
every 4 hours for adults
every 2 hours for 9-17
every hour for less than 9 years old 
check on client q 15 minutes
26
Q

with psych clients

A

stay away from sedation meds and restraints

27
Q

anxiety

A

universal emotion but becomes a disorder when it interferes with day to day functioning
need step by step instructions

28
Q

generlized anxiety disorders
s/s
tx

A

chronic anxiety, always seeks help, fatigue

tx: short term use of anxiolytics, relaxation techniques, re channel anxiety through exercise
* pick most exerting answer*

29
Q

panic disorders

A

client may be seen as having an MI

TX: stay with the client in a non threatening way, breathe with them, use simple words

30
Q

phobias

A

desensitizations is key to recovery and must occur overtime (gradual exposure to fear)
do not talk about phobias a lot

31
Q

OCD

A

obsessive thoughts and compulsion is a recurrent act

tx: structured schedule, provide distraction techniques to distance themselves from anxiety producing thoughts

32
Q

anorexia

A

lanugo, decreased sexual development, lose weight, hypothermia
tx: weight them in their underwear, monitor exercise, allow clients input into choosing healthy foods

33
Q

bulimia

A

overeat then vomit
teeth erosion, laxative and diuretic use, normal weight
tx: sit with client 1 hour after eating, allow 30 minutes to eat

34
Q

ptsd

A

emotional numbness, difficulty with relationships, isolate themselves
tx: establish sense of safety, support groups,

35
Q

alcohol med

A

chlordiazepoxide- anxiolytic that is frequently used for outpatient detox
B vitamins for brain function

36
Q

alcohlists defense mechanisms

A

rationalization and denial

37
Q

opiate intoxication

A

pinpoint pupils, respiratory depression, coma

38
Q

opioid withdrawl

tx

A

anxious, nausea, vomiting, muscle aches, excessive tearing and running nose, sweating, pupil dilation
tx: methadone- dont get addicted to this

39
Q

s/s of hemothorax/pneumothorax

tx

A

SOB, diminished breath sounds on affected side, less movement on affected side, chest pain
tx: thoracentesis, chest tube, daily chest x ray

40
Q

tension pneumo
what is it
causes
s/s

A

pressure has built up in the chest/pleural space and has collapsed the lung

  • too much PEEP, clamping a chest tube, taping all 4 sides without an air valve
  • asymmetry of thorax, resp distress, cyanosis, JVD, absence of breath sounds on one side
41
Q

open pneumo thor

what is it and tx

A

opening through chest that allows air into the pleural space
tx: have client inhale and hold or valsalva or hummmmm to increase the intra-thoracic pressure so no more outside air can get into the body then tape 3` sides down

42
Q

what is the purpose of a water seal chamber

A

to promote one way flow out of the pleural space which will prevent air from moving back up the system and into the pleural space
may see bubbling in this chamber when the client coughs, sneezes, or exhales
might see a slight rise and fall of water as the client breathes - tidaling. NORMAL

43
Q

suction control chamber

A

controls the amount of pressure applied. slow, gentle bubbling is normal

44
Q

anytime you see peep, cpap, or bi pap your priority is

A

check lung sounds bilaterally

45
Q

bipap

A

pressure applied at two different pressure settings. one on inhalation and a lower pressure on exhalation

46
Q

cpap

A

pressure is delivered continuously during inspiration and expiration

47
Q

pulmonary embolism
s/s
best test

A

thrombosis that has broken off and lodges in a lung artery
s/s: hypoxemia, chest and back pain on inspiration increase RR, restlessness, petechiae over chest, hemoptysis (coughing up blood), increase pulse, increase BP
test: pulmonary angiography

48
Q

aPTT

A

30-40 seconds

49
Q

PT

A

11-12.5 seconds

50
Q

INR

A

0.8-1.1

51
Q

prevention of pulmonary embolism

A

change position every 2 hours, TED hose, hydrate by forcing fluid,prevent stasis by flexing and extnding feet, knees, and hips every 2-4 hours

52
Q

while on warfarin

A

limit green leafy vegetable servings to what is normally eaten. do not increase servings

53
Q

complications of alcohol use disorder

A 
thiamine and niacin
korsakoffs syndrome
wernickes syndrome
gastritis
Mg and K 
SEIZURES 
delirium tremens
liver and pancreas prob

NCLEX (17 decks)

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