Test 2 review questions from lecture Flashcards
The gcs assesses?
arousal
decorticate motor response indicates
cerebral hemispheric dysfunction
Pupils are bilaterally pinpoint andn nonreactive to light. What does this indicate?
severe herniation
in cases of brain stem injury dolls eye movement will remain
fixed at the midpoint position
rhythmic waxing and wayning followed by period of apnea
cheyne stokes
elevated wave form on monitor that is clinically significant
a wave
During administration of t-PA the nurse should perform neurovascular checks?
- Every 15 minutes
- Every hour
- Every 4 hours
- Every shift
Every 15 minutes
during assessment the pt. asks if something is burning. Nurse realizes the pt. is demonstrating?
a focal seizure
preparing to administer med to pt. to reduce cerebral edema caused by a brain tumor. Med is most likely?
glucocorticoid med (mannitoL)
plan of care after posterior fossa surgery?
assess vital signs every 15 minutes
a pt. after craniotomy and has a headache, hob elevated, damp mark on pt. pillow. Nurse should?
alert physician, check for glucose in drainage
pt with intracerebral hemmorrhage. What is most common cause?
HTN
major management goals in caring for the donor patient include
maintain stable hemodynamic status, fluid and electrolute balance, optimal oxygenation
general guidelines in determination of organ transplant include?
- Children have priority over adults
- Body habitus
- Blood group
- Human leukocyte antigens (HLA) match
- High panel reactive antibody (PRA) score: highly sensitized recipients
pt is considered apneic if paco2 is
greater than 60, or greater than 20 rise above the baseline
A 30 year old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?
- bladder distention
- neurologic deficit
- pulse ox readings
- clients feelings about the injury
bladder distention
While in the ER, a client with c8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR 18. The nurse suspects which of the following onditions?
- autonomic dysreflexia
- hemorrhagic shock
- neurogenic shock
- pulmonary embolism
neruogenic shock
a 22 yr old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a hr of 50bpm. Which of the following nursing interventions should be done first?
- place the client flat in bed
- assess patency of the indwelling urinary catheter
- give one SL nitroglycerin tab
- raise the head of the bed immediately to 90 degrees
assess patency of the indewelling urinary catheter
The nurse is caring for an elderly client diagnosed with a herniated nucleus pulposus of l4-l5. Which scientific rationale explains the incidence of a ruptured disk in the elderly?
- the client did not use good body mechanics when lifting an object
- there is an increased blood supply to the back as the body ages
- older clients develop atherosclerotic joint disease as a result of fat deposits
- client develop intervertebral disc degeneration as they age
clients develop intervertebral disc degeneration as they age
A client is admitted with a spinal cord injury at the level of t12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord?
- acetazolamide (diamox)
- furosemide (lasix)
- methylprednisolone (Solu-Medrol)
- Sodium bicarbonate
methylprednisolone (solu-medrol)
A client with a cervical spine injury has gardner-wells tons inserted for which of the following reasons?
- to hasten wound healing
- to immobilize the surgical spine
- to prevent autonomic dysreflexia
- to hold bony fragments of the skull together
immobilize the surgical spine
Which of the following interventions describes an appropriate bladder program for a client in rehab
- insert an indewelling urinary cath to straight drainage
- schedule internittent cath every 2-4 hours
- perform a straight cath every 8 hrs while awake
- perform crede’s maneuver to the lower abdomen before the client voids
schedule intermittent cath every 2-4 hours
A client has a cervial spine injury at the level of c5. Which of the following conditions would the nurse anticipate during the acute phase?
- absent corneal reflex
- decerbate posturing
- movement of only the right or left half ot the body
- the need for mechanical ventilation
the need for mechanical vent
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observaions by the nurse indicates that spinal sock persists?
- positive reflexs
- hyperreflexia
- inability to elicit a babinski reflex
- reflex emptying of the bladder
inability to elicit the babinski reflex
Your t1 spinal cord injured patient complains of a headache. You should?
- give him prn tylenol
- disempact his bowels
- call the dr.
- take hid BP
take his blood pressure
What can the nurse do to best speed the patients recovery from a laminectomy of L5?
- keep pt. flat in bed
- teach the back school approach
- medicate for pain q2 hrs
ambulate as soon as orders permit
keep the patient flat in bed
Your patient has a malignant metastatic lesion at t8 and is in for palliative radiation. What is your main goal with this patient?
- teach self cath
- ensure pt. recieved pain meds as needed
- encourage pt. to discuss fears
- ambulate twice a shift
ensure patient receives pain medication as needed
