Psychiatric Nursing + Neuro Flashcards

Question

Carbamazepine | Tegretol

Answer 1

``` Acute mania associated with bipolar disorder. Alcohol withdrawal Seizure disorder Trigeminal neuralgia Diabetic neuropathy ``` ``` PO/Slow Interactions: Increase CNS toxicity with Lithium. Fatal reaction with use of MAOIs. Decrease anticonvulsant effect with use of St. John’s wort. ``` ``` Side Effects: Drowsiness Dizziness Confusion Fatigue Headache Hallucinations Tinnitus Dry mouth Blurred vision Photosensitivity Constipation Diarrhea Nausea/vomiting ``` ``` Adverse Effects: A plastic anemia Agranulocytosis Respiratory depression Arrhythmias AV block Stevens-Johnson Syndrome ``` Interventions: Monitor drug effectiveness. Assess urinalysis, BUN, creatinine q 3 months. Provide hard candy, gum, frequent rinses for dry mouth. Education: Carry emergency ID regarding medication. Avoid driving and other activities that require alertness. Report chills, rash, light colored stools, dark urine, jaundice. Urine may turn pink to brown.

Answer 2

``` Used in Mania Schizophrenia Seizure disorder Migraine prophylaxis Unlabeled: Febrile seizures ``` ``` PO Interactions: Increase risk of toxicity with erythromycin, salicylates, NSAIDs. Increase CNS depression with alcohol, opioids, barbiturates, MAOIs, tricyclics. ``` ``` SIde Effects: Drowsiness Dizziness Headache Weakness Nausea/Vomiting Diarrhea Constipation Dyspepsia Weight loss ``` ``` Adverse: Bone marrow depression Pancreatitis Hepatotoxicity Stevens-Johnson syndrome Coma/Death with overdose ``` Interventions: Monitor mental status, mood activity, sleeping/eating behavior, suicidal thoughts. Monitor CBC, PT/PTT, serum ammonia, platelets. Monitor for signs of pancreatitis. Education: Physical dependency may result from extended use. Avoid driving, other activities that require alertness Drink plenty of fluids. Report visual disturbances, rash, abdominal pain, lightcolored stools, jaundice, protracted vomiting

Answer 3

Mania and Bipolar disorder ``` Contraindications: Children < 12 years Thyroid disease Liver disease Renal disease ``` Interactions May increase lithium level with thiazide, methyldopa, haloperidol, NSAIDS, calcium channel blockers, ACE inhibitors. May increase hyperglycemia with antidiabetics. Caffeine may decrease lithium levels MoA: Alteration of ion transport in muscle and nerve cells. Increased receptor sensitivity to serotonin. Long term therapy may cause hypothyroidism ``` Side Effects: Headache Memory impairment Blurred vision Metallic taste Dental caries Lethargy Drowsiness Tremors Slurred speech Dry mouth Anorexia Vomiting Diarrhea Polyuria Dehydration ``` ``` Adverse Effects: Toxic effects: tremor, confusion, seizures, death. Hypotension Hyperglycemia Hyponatremia Proteinuria Cardiac dysrhythmias ``` Intervention: Monitor serum sodium (Normal serum sodium helps to maintain therapeutic lithium levels). Frequently monitor Lithium level (Therapeutic range – 1-1.5 mEq/L for acute mania; Maintenance levels are 0.6-1.2 mEq/L. Levels exceeding 1.5-2.5 mEq/L begin to produce toxicity. Normal levels and toxicity levels are very close). Education: Maintain adequate fluid intake of 1-2 L daily. Importance of lab tests and follow-up visits. Do not drive until stable lithium level. Take with meals to decrease gastric irritation. Wear ID indicating medication taking.

Answer 4

Common uses: Facilitation of ET intubation. Skeletal muscle relaxation. ``` Contraindications: Hypersensitivity Malignant hyperthermia Trauma ``` ``` IM/IV Interactions: Increase dysrhythmias with theophylline. Melatoninblocks succinylcholine. Increase neuromuscular blockade with aminoglycosides, beta blockers, glycosides, procainamide, lithium, opioids, thiazides. ``` MoA: Inhibits transmission of nerve impulses by binding with cholinergic receptor sites, thus antagonizing action of acetylcholine. Causes release of histamine. ``` Side Effects: Bradycardia Tachycardia Flushing Weakness Muscle pain Increased secretions ``` ``` Adverse Effects: Sinus arrest Dysrhythmias Myoglobulinemia Rhabdomyolysis Apnea Bronchospasm Respiratory depression Anaphylaxis Angioedema ``` Interventions: Monitor for electrolyte imbalances: May lead to increased action of product. Monitor vital signs until fully recovered. I&O Check for urinary retention, frequency, hesitancy. Client Education: Use of medication, Care during recovery

Answer 5

``` Common uses: Acute and chronic psychosis Schizophrenia resistant to other medications. Tourette’s syndrome Paranoia Children with severe behaviour problems who are combative. Suppress narcotic withdrawal. ``` ``` Contraindications: Narrow angle glaucoma Severe hepatic, renal, cardiovascular disease. Parkinson’s disease Bone marrow depression ``` ``` PO/IM/IV Interactions: Increase sedation with alcohol, CNS depressants. Increase toxicity with anticholinergics, CNS depressants, Lithium. Decrease effects with phenobarbital, caffeine. ``` MoA: Blocks the dopamine receptors. ``` SIde Effects: Tachycardia Urinary retention Constipation Blurred vision Headache Dry mouth Nausea/vomiting Weight gain Photosensitivity ``` ``` Adverse effects: Seizures Respiratory depression Laryngospasm Dysrhythmias Neuromalignant syndrome Tardive dyskinesia Orthostatic hypotension ``` Interventions: Assess CBC Obtain BP lying, sitting, standing. Monitor for dizziness, faintness, tachycardia on rising. Monitor for EPS. Supervise ambulation until client stabilized on medication. Provide sips of water, sugarless candy, gum for dry mouth Education: Rise slowly from lying or sitting position. Avoid hazardous activities until stabilized on medication. Avoid abrupt withdrawal of medication. Avoid OTC preparations. About EPS. Oral care. Report impaired vision, jaundice, tremors, muscle twitching

Answer 6

Common uses: Opiate addiction Alcoholism Nicotine withdrawal Contraindications: opioid dependence PO/IM Interactions: Increased lethargy with phenothiazines Increased hepatotoxicity with disulfiram. Increased bleeding risk with anticoagulants. ``` Side Effects: Stimulation Drowsiness Dizziness Confusion Headache Flushing Nervousness Irritability Anxiety Tinnitus Blurred vision Diarrhea Constipation Impotence Nausea/vomiting ``` ``` Adverse Effects: Seizures Suicidal ideation Pulmonary edema DVT Hepatotoxicity ``` Interventions: Give with food, antacid to prevent N/V. Do not give until opioid free for 7-10 days to prevent opioid withdrawal. Administer IM deep in gluteal. Alternate injection sites. Aspirate before injection. Monitor cardiac status and respiratory function. Education: Must be drug free to start treatment. Using opioid while taking this medication could be fatal. Carry emergency ID. Use caution while driving or performing hazardous tasks. Report suicidal thoughts.

Answer 7

Used for migraine headaches Contraindications: BF, Heart disease and HTN SL/Intranasal/IM/IV Interactions: Severe hypertension can occur with the use of Droxidopa or sympathomimetics. Risk of increase ergotamine side effects can occur with Azole antifungals, beta-blockers, fluconazole, fluoxetine, fluvoxamine, HIV protease inhibitors, sumatriptan, macrolide antibiotics. Advantages: Can be used to prevent or treat acute migraine headache with or without an aura. Disadvantages: Toxicity may occur Side effects: Dizziness, Nausea/vomiting Adverse Effects: Angioedema Chest pain Arrhythmias Muscle pain SOB Interventions: Assess frequency, location, duration, and characteristics headaches. During acute attack, assess type, location, and intensity of pain before and 60 min after administration. Monitor BP and peripheral pulses periodically during therapy. Report any increases in BP. Assess for nausea and vomiting. Assess for toxicity manifested by severe ergotism (chest pain, abdominal pain, persistent paresthesia in the extremities) and gangrene. Vasodilators, dextran, or heparin may be ordered to improve circulation. Education: Proper use of inhaler. Take at the first sign of a migraine attack. Do not swallow, crush, or chew sublingual tablets. Do not eat, drink, or smoke while tablet is dissolving. If more than 1 dose needed to treat a migraine, take the second dose at least 30 minutes after the first dose. Do not take more than 2 tablets for any migraine attack. Do not take more than 3 tablets in a 24 hour period. Do not take more than 5 tablets within a 7 day period. Do not use ergotamine daily on a regular basis.

Answer 8

Used in Migraine headaches and cluster headaches. ``` Contraindications: History of coronary artery disease, uncontrolled hypertension, cerebrovascular disease, MI. Obesity, diabetes, smoking, hepatic disease ``` ``` Po/SubQ/Intranasal Interactions: Increase vasospastic effects with ergot derivatives. Increase serotonin syndrome with SSRIs ``` MoA: Causes vasoconstriction of cranial arteries to relieve migraine headaches. ``` Side Effects: Nausea/vomiting Dizziness Numbness Tingling Dry mouth Diarrhea Abdominal cramping ``` ``` Adverse Effects: Hypertension Hypotension Cardiac arrhythmias MI Seizures Stroke Coronary artery vasospasms ``` Interventions: Assess type of headache, pain, aura, alleviating and aggravating factors. Monitor for serotonin syndrome (delirium, coma, agitation, diaphoresis, hypertension, fever, tremors). Monitor BP, ECG Monitor neurologic status Education: Keeping a journal: Ingestion of tyramine foods, food additives, preservatives, coloring, artificial sweeteners, chocolate, caffeine, may precipitate a migraine attack. Report chest pain or tightness, sudden and severe abdominal pain, swelling around eyes, face, lips. Do not use for more than 3-4 headaches per month. Nasal spray: Use 1 spray in 1 nostril. Repeat if headache returns, but not if pain continues after 1st dose. Lie in dark, quiet environment. Avoid hazardous activities if dizziness, drowsiness occurs. Avoid alcohol: may increase headache.

Answer 9

Serotonin is a chemical produced by the body that enables brain cells and other nervous system cells to communicate with one another. Too little serotonin in the brain is thought to play a role in depression. Too much, however, can lead to excessive nerve cell activity, causing a potentially deadly collection of symptoms known as serotonin syndrome. Serotonin Syndrome Symptoms Serotonin syndrome symptoms often begin within hours of taking a new medication that affects serotonin levels or excessively increasing the dose of one you are already taking. Symptoms may include: ``` Confusion Agitation or restlessness Dilated pupils Headache Changes in blood pressure and/or temperature Nausea and/or vomiting Diarrhea Rapid heart rate Tremor Loss of muscle coordination or twitching muscles Shivering and goose bumps Heavy sweating In severe cases, serotonin syndrome can be life threatening. If you experience any of these symptoms, you or someone with you should seek medical attention immediately: ``` High fever Seizures Irregular heartbeat Unconsciousness

Answer 10

Common Uses: Muscle spasms. Baclofen and Dantrium: multiple sclerosis, cerebral palsy. PO/Intrathecal/IM/IV Interactions: CNS depression with alcohol, tricyclics, opiates, barbiturates, sedatives. Increase hypotension with antihypertensives. MoA: Inhibits synaptic responses in CNS by stimulating GABAb receptors. This decreases neurotransmitter function; decreases frequency, severity of muscle spasms. ``` Side Effects: Dizziness Drowsiness Fatigue Lightheadedness Dry mouth Muscle weakness Constipation Urinary retention Anorexia Nausea/vomiting ``` ``` Adverse Effects: Hypotension Bradycardia Angioedema Anaphylaxis Hepatotoxicity CNS depression Seizures ``` Interventions: Assess spasms, spasticity, ataxia for improvement with medication. Assess BP, weight, glucose, hepatic function studies periodically. Monitor ALT, AST with long-term Dantrium use. I&O Education: Methocarbamol may turn urine green, brown, or black. Take with meals for GI symptoms. Do not discontinue abruptly. Do not take with alcohol, other CNS depressants. Avoid hazardous activities if drowsiness/dizziness occurs.

Answer 11

Parkinson's disease is a progressive disorder of the nervous system that affects movement. It develops gradually, sometimes starting with a barely noticeable tremor in just one hand. But while a tremor may be the most well-known sign of Parkinson's disease, the disorder also commonly causes stiffness or slowing of movement. In the early stages of Parkinson's disease, your face may show little or no expression, or your arms may not swing when you walk. Your speech may become soft or slurred. Parkinson's disease symptoms worsen as your condition progresses over time. Tremor. A tremor, or shaking, usually begins in a limb, often your hand or fingers. You may notice a back-and-forth rubbing of your thumb and forefinger, known as a pill-rolling tremor. One characteristic of Parkinson's disease is a tremor of your hand when it is relaxed (at rest). Slowed movement (bradykinesia). Over time, Parkinson's disease may reduce your ability to move and slow your movement, making simple tasks difficult and time-consuming. Your steps may become shorter when you walk, or you may find it difficult to get out of a chair. Also, you may drag your feet as you try to walk, making it difficult to move. Rigid muscles. Muscle stiffness may occur in any part of your body. The stiff muscles can limit your range of motion and cause you pain. Impaired posture and balance. Your posture may become stooped, or you may have balance problems as a result of Parkinson's disease. Loss of automatic movements. In Parkinson's disease, you may have a decreased ability to perform unconscious movements, including blinking, smiling or swinging your arms when you walk. Speech changes. You may have speech problems as a result of Parkinson's disease. You may speak softly, quickly, slur or hesitate before talking. Your speech may be more of a monotone rather than with the usual inflections. Writing changes. It may become hard to write, and your writing may appear small. NOT GRIPPY SHOES

Answer 12

A common form of dementia. Alzheimer's is a type of dementia that causes problems with memory, thinking and behavior. Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks. Memory loss that disrupts daily life Challenges in planning or solving problems Difficulty completing familiar tasks at home, at work or at leisure Confusion with time or place Trouble understanding visual images and spatial relationships New problems with words in speaking or writing Misplacing things and losing the ability to retrace steps Decreased or poor judgment Withdrawal from work or social activities Changes in mood and personality

Answer 13

Always identify yourself and call clients by name Speak slow Use short simple sentences and words. Focus on one piece of info at a time. Communicate face to face with one to two arms length distance to help attn and maximize vernal and non verbal cues Talk about meaningful things - Helps client to focus on a successful life and increases self esteem Do not reminisce if client has a troubled life Keep clocks calenders or personal items within reach and vision. mark calender with a X for each day

Answer 14

Always identify yourself and call clients by name Speak slow Use short simple sentences and words. Focus on one piece of info at a time. Communicate face to face with one to two arms length distance to help attn and maximize vernal and non verbal cues Talk about meaningful things - Helps client to focus on a successful life and increases self esteem Do not reminisce if client has a troubled life Keep clocks calenders or personal items within reach and vision. mark calender with a X for each day Glasses and Hearing aids are accessible Identify all doors Monitor food or fluid intake Weigh Weekly Group activities Dress in their own clothes Calm Use their capacity to maintain self esteem

Answer 15

Normal in a child up to 1 year, Abnormal in an adult. In adult, it means that there is a severe problem in the central nervous system ( tumor, lesion on the brain or spinal cord, MS, ALS)

Answer 16

Document as 2+/4+ for a normal reflex

Answer 17

``` With or Without contrast Consent needed before test Takes pictures in slices/layers Keep head still No Talking ```

Answer 18

MRI picks up on pathology earlier Dye is used sometimes. No radiation, A magnet TUBE Remove jewellery, Credit cards, Pacemakers Tattoos matter because old ones have lead in them/ shrapnel in veterans THUMPING SOUND don't do this for claustrophobic clients Can talk and hear others while in the tube

Answer 19

Consent for dye Goes through the Femoral Artery Pre Procedure Well hydrated/ void/ PP/ Groin prepped/complete neuro assessment Anytime an iodine based dye is used, the client will need to be well hydrated to promote excretion of the dye WATCH BUN CREATININE UO and hold metformin Explain that they will have warmth in the face and a metallic taste Allergies: Iodine and shellfish is a NO Post Procedure Bed rest for 4 to 6 hours Watch for bleeding at femoral site Possible complication is embolus An embolus can go alot of different places. - Arms (decreased circulation/ DVT), Heart (MI), Lung (PE) and Kidney (decreased Kidney function), Brain (Decreased LOC) Client will have change of LOV, one sided weakness and paralysis and moto/sensory deficits

Answer 20

Records electrical activity of the brain Helps diagnose seizure disorders and evaluate the types of seizures occuring Evaluates loss of consciousness and dementia Screening procedure for coma Indicator of brain death Used to diagnose sleep disorders like narcolepsy, cerebral infarct and brain tumors or abcesses Pre Procedure HOLD sedatives because it decreases electrical activity No caffeine NO NPO Beginning of procedure Will get a baseline first with client lying quietly May be asked to hyperventilate to assess brain circulation, assess photo stimulation for seizures or sedate for sleep study If you have someone completely unconscious, a pain response or noxious stimuli may be introduced to stimulate a brain wave. This can be anything from a strong smell like ammonia to a bright light.

Answer 21

Into the lumbar subarachnoid space Purpose is to obtain spinal fluid to analyze for blood, infection and tumor cells To measure pressure readings with a manometer To admin drugs intrathecally ( brain, spinal cord) Back is arched with head down or Side lying fetal position Inspect the surrounding skin at the puncture site for any infection SF should be like WATER Post procedure Lie flat or prone for 2 -3 hours Increase Fluids to replace the lost spinal fluid Common complication is headache - pain increases when the client sits up and decreases when they lie down How is this headache treated? Bed rest, fluids, pain meds and a blood patch to instantly seal puncture site Life threatening complications: Brain herniation: With known increasedICP, a lumbar puncture is contraindicated. Meningitis Bacteria get into the puncture site and spinal fluid

Answer 22

``` Earliest sign is a change in LOC Speech is slurred or slowed Delay in response to verbal suggestion - Slow to respond to commands Increasing drowsiness Restless with apparent reason Confusion ```

Answer 23

Marked change in LOC progressing to stupor then coma Vital sign changes: CUSHINGS TRIAD - requires emergency intervention to prevent brain brain ischemia Cushing Triad: Systolic hypertension with a with a widening pulses pressure/ Slow full and bounding pulse/ Irregular respirations

Answer 24

Changes in vitals Posturing: A response to pain or noxious stimuli Posturing indicates that the motor response centers of the brain are compromised. Decorticate/Decerebrate Posturing - Client will be rigid, tight and burning more calories Misc Signs: Headaches Changes in pupils and response. (In profound coma - fixed and dilated) Projectile vomiting can occur because the vomiting center in the brain is being stimulated

Answer 25

Arms flexed inward and bent in toward to the body and the legs are extended

Answer 26

All four extremities in rigid extension; THIS IS WORST. Indicates serious brain damage.

Answer 27

Brain Herniation: This herniation obstructs the blood flow to the brain leading to anoxia and then death DI and SIADH: Can be either, so you must assess for both.

Answer 28

Maintain Oxygenation : Decreased O2 levels and high CO2 levels cause cerebral vasodilation which increase ICP ( so they should be on a ventilator) Maintain Cerebral Perfusion: Don't want tachycardia or bradycardia because that decrease brain perfusion. Isotonic saline and inotropic agents: dobutamine and norepinephrine (vasodilation) Keep temperature below 38 degree: An increased temperature will increase cerebral metabolism which ICP. The hypothalamus may not be working properly, and a cooling blanket may be needed. Hypothermia is used as a treatment to decreasing the metabolic demands of the brain Elevate the HOB Keep head midline so the jugular veins can drain Watch the ICP monitor with turning etc Avoid restraints, bowel/bladder distention, hip flexion, Valsalva, and isotremics. No sneezing and no nose blowing. Limit suctioning and coughing Spaced nursing interventions - Anytime you do something to your client, ICP increases. Monitor the Glasgow coma scale ( Under 8 intubate) Monitor vital signs for Cushing's Triad Barbiturate induced coma - decreases cerebral metabolism: phenobarbital Osmotic Diuretics: Mannitol - Draws fluid from the brain cells and filters it out through the kidneys ( MAKE SURE U USE A FILTER) This decreases the ICP Steroids - dexamethasone decreases the cerebral edema ``` ICP monitoring devices: Vent. cath monitor or subarachnoid screw Greatest risk is infection No loose connections Keep dressing Sterile and dry ```

Answer 29

Inflammation of the spinal cord or brain. CAn be Viral or bacterial. Chills and fever, Severe Headache, Nausea and Vomiting, Nuchal Rigidity, Photophobia Treatment: Steroids: Decrease Inflammation Antibiotics if bacterial Analgesics Droplet precautions for bacterial ( very contagious, medical emergency, high mortality, immunization recommended in college students) Contact precautions for viral meningitis as it is transferred through poop

Answer 30

Should be thought of as a symptom of an under;ying disorder rather than a disease Not considered epilepsy if they discontinue once the disease has gone away

Answer 31

Limited to a specific local area of the brain An aura may be the only manifestation - perceptual disturbances ( called focal seizures) Symptoms can range from simple to complex Simple means without loss of consciousness; will see numbness, tingling, prickling or pain Complex means impaired consciousness, confused and unable to respond

Answer 32

Also known as NON-FOCAL Involves the entire brain. Loss of consciousness is the initial manifestation

Answer 33

formerly known as grand mal. The tonic phase comes first. All the muscles stiffen. Air being forced past the vocal cords causes a cry or groan. The person loses consciousness and falls to the floor. A person may bite their tongue or inside of their cheek. If this happens, saliva may look a bit bloody. After the tonic phase comes the clonic phase. The arms and usually the legs begin to jerk rapidly and rhythmically, bending and relaxing at the elbows, hips, and knees. After a few minutes, the jerking slows and stops. The person’s face may look dusky or a bit blue if they are having trouble breathing or the seizure lasts too long. The person may lose control of their bladder or bowel as the body relaxes. Consciousness, or a person’s awareness, returns slowly. These seizures generally last 1 to 3 minutes. Afterwards, the person may be sleepy, confused, irritable, or depressed. A tonic-clonic seizure that lasts longer than 5 minutes needs immediate medical help. Call 911 for emergency help. A seizure that lasts more than 10 minutes, or three seizures in a row without the person coming to between them, is a dangerous condition. This is called status epilepticus; emergency treatment in a hospital is needed.

Answer 34

Sudden brief contractions of a muscle or group of muscles

Answer 35

Formerly called petit mal and characterized by a brief loss of consciousness

Answer 36

Status Epilepticus: a continuous seizure without returning to consciousness between seizures Trauma: Protect the client - can be severe/cause death

Answer 37

Neurological examination including lab and xray Anticonvulsants: Can be long or short term therapy. Rapid acting -lorazapam and diazepam. Long acting - phenytoin or phenobarbital Have toxic effects - monitor for drug toxicity - Abrupt withdrawal can cause a seizure. Don't forget the basics of airway and safety during a seizure. DON'T PUT SHIT IN THEIR MOUTH

Answer 38

May/May not damage Brain Open fracture - dura is torn Closed Fracture - Dura is NOT torn With a basal skull fracture, you see bleeding EENT Battles Sign: Bruising over the mastoid Raccoon eyes ( peri-orbital bruising) Cerebrospinal rhinorrhea- leaking spinal fluid from NOSE it is CSF if it tests positive for glucose and the halo test Non-depressed skull fractures usually do not require surgery; depressed fractures do require surgery.

Answer 39

Temporary loss of neurologic function with complete recovery Will have a short period of unconsciousness or may just get dizzy/see spots Teach caregiver to bring client back to ED if the following occur: Difficulty awakening/speaking, confusion, severe headache, vomiting, pulse changes, unequal pupils, one sided weakness (all signs of increasing ICP)

Answer 40

A small Hematoma that develops rapidly may be fatal while a massive hematoma that develops slowly may allow the client to adapt

Answer 41

This is rupture of the middle meningeal artery (fast bleeder under high pressure) Injury - loss of consciousness - Recovery period - can't compensate any longer - neuro changes (agitation, restlessness, seizures, posturing) Treatment: Burr hole and remove the clot; control the ICP Ask questions to ID the type of injury and the treatment needed -Did they pass out and stay out? - Did they pass out then wake up and pass out again? Did they just see stars? Epidural Hematoma is an emergency

Answer 42

Usually a slow bleed ( usually venous) Can be acute, subacute or chronic ( usually imitates other conditions) Bleeding and compensating Neuro changes = maxed out Acute or chronic: Immediate crainiotomy and remove clot - control the ICP

Answer 43

With upper spinal cord injury (above T6), the major complication to look for is this or hyperreflexia Severe HTN, Headache, Bradycardia, Nasal stuffiness, flushing, sweating, blurred vision and anxiety Sudden onset. It is a medical emergency - if not treated, a hypertensive stroke can occur Caused by distended bladder, constipation or painful stmuli Treatment SIT CLIENT UP to lower blood pressure Treat the cause - put in cath, remove impaction, look for skin pressure, painful stimuli or cool draft in room Take prevention measures

Answer 44

Can induce tonic clonic seizures Is useful for clients with severe depression Pre procedure NPO, Void, atropine given to prevent aspiration A signed consent is necessary Succinylcholine is given to relax muscles Given as a series of treatments depending on the client response Post procedure Position client on side to prevent aspiration Stay with client Temporary mem loss is expected REorientate them repeatedly Return to day to day functioning as soon as possible

Answer 45

Focus is inward. They create their own world Inappropriate affect, flat affect or blunted affect Disorganized thoughts ( looseness of associations) Ineffective communication skills: Communication is one of their biggest problems ``` Echolalia - Hear a word and repeat it Neologism - making up new words Word Salad Concrete thinking Religiosity Delusions Hallucinations ``` Nursing Considerations Decrease Stimuli Observe frequently without looking suspicious Orient frequently Keep conversations reality based Observe for hallucinations ( warn before you touch them) Don't refer to the voices as they because this makes th hallucinations seem real Let the client know you do not share the perception Hallucinations are connected to times of anxiety Get them involved in ACTIVITY Turn off the TV Offer reassurance because the client is frightened Command Hallucinations

Answer 46

Always suspicious Cannot explain away their delusions or paranoid beliefs Pathologic jealousy Hypersentitive to comments or actions Can't relax - no humor - unemotional Abnormal anger response, responds with rage when provoked - always rationalizes behaviour ``` Treatment Be reliable Your goal is to build trust. If you say you will do something, you must do it ! Be honest Consistent nurses and brief visits Be matter of fact Respect personal spaces Be careful with rouch Don't mix meds, and always ID them May need to eat sealed food ```

Answer 47

Can be used when the nurse assesses that the client is a danger to themselves or others Used as a last resort Client must be evaluated in person by a PHP within one hour of restraints Orders must be renewed every 4 hours for adults, Every 2 Hours for 9 - 17 and Every hour for less than 9 Check client face to face every 15 minutes Remember hydration, nutrition and elimination. Provide something to eat/drink and use of the washroom Client can suffocate and die while in restraints

Answer 48

is a psychological disorder that develops from stress, resulting in medically unexplainable physical symptoms (eg, abdominal pain) that disrupt daily life. Clients with SSD focus an excessive amount of time, thought, and energy on the symptoms, often seeking medical care from multiple health care providers. Nursing interventions focus on minimizing indirect benefits and developing client insight. To minimize the indirect benefits from being "sick" (secondary gains), the nurse should: Redirect somatic complaints to unrelated, neutral topics Limit time spent discussing physical symptoms (Option 2) To promote insight and healthy coping mechanisms, the nurse should assist the client to: Identify secondary gains (eg, increased attention, freedom from responsibilities) Recognize factors that intensify symptoms (eg, increased stress, reminders of a deceased family member) Incorporate appropriate coping strategies (eg, relaxation training, physical activity)

Answer 49

The olfactory nerve (I): This is instrumental for the sense of smell, it is one of the few nerves that are capable of regeneration.

Answer 50

The optic nerve (II): This nerve carries visual information from the retina of the eye to the brain.

Answer 51

The oculomotor nerve (III): This controls most of the eye’s movements, the constriction of the pupil, and maintains an open eyelid.

Answer 52

The trochlear nerve (IV): A motor nerve that innervates the superior oblique muscle of the eye, which controls rotational movement.

Answer 53

The trigeminal nerve (V): This is responsible for sensation and motor function in the face and mouth.

Answer 54

The abducens nerve (VI): A motor nerve that innervates the lateral rectus muscle of the eye, which controls lateral movement.

Answer 55

The facial nerve (VII): This controls the muscles of facial expression, and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue and oral cavity.

Answer 56

The vestibulocochlear nerve (VIII): This is responsible for transmitting sound and equilibrium (balance) information from the inner ear to the brain.

Answer 57

Cranial nerve IX (glossopharyngeal) is involved in the gag reflex, ability to swallow, phonation, and taste. Postoperative partial laryngectomy clients will need to undergo evaluation by a speech pathologist to evaluate their ability to swallow safely to prevent aspiration. Clients are taught the supraglottic swallow, a technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration. Clients are instructed to: Inhale deeply Hold breath tightly to close the vocal cords Place food in mouth and swallow while continuing to hold breath Cough to dispel remaining food from vocal cords Swallow a second time before breathing

Answer 58

The vagus nerve (X): This is responsible for many tasks, including heart rate, gastrointestinal peristalsis, sweating, and muscle movements in the mouth, including speech and keeping the larynx open for breathing.

Answer 59

The spinal accessory (XI): This nerve controls specific muscles of the shoulder and neck.

Answer 60

The hypoglossal nerve (XII): This nerve controls the tongue movements of speech, food manipulation, and swallowing.

Answer 61

is an inflammation of cranial nerve VII (facial) that causes motor and sensory alterations. Clients are usually managed as outpatients, with corticosteroids to reduce inflammation, and taught eye/oral care. In Bell's palsy, the eyelids do not close properly. This may result in eye dryness and risk of corneal abrasions. However, weakness of the lower eyelid may cause excessive tearing due to overflow in some clients. Facial muscle weakness results in poor chewing and food retention. Client teaching should include the following: Eye care: Use glasses during the day; wear a patch (or tape the eyelids) at night to protect the exposed eye. Use artificial tears during the day as needed to prevent excess drying of the cornea. Oral care: Chew on the unaffected side to prevent food trapping; a soft diet is recommended. Maintain good oral hygiene after every meal to prevent problems from accumulated residual food (eg, parotitis, dental caries) Bell's palsy is an inflammation of cranial nerve VII (facial) that results in facial muscle weakness and inability to close the eyelids. Eye care (patch at night, artificial tears as needed) and oral care (eating on the unaffected side, oral hygiene after meals) are vital for these clients.