Multidimensional Care IV Exam 3, Exams of Nursing

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NUR 2755 Multidimensional Care IV Exam 3

Rasmussen 2024 Graded A+

MDC 4 Exam 3

1. muscle weakness increase uncordination confusion apathy incoherence decreased clotting Pneumothorax interventions MS physical assessment Frsotbite physical assessment Moderate hypothermia symptoms 2. worst headache ever subarachnoid hemorrhage symptom Spinal Cord Injury Intervention Right hemisphere stroke changes Guillian Barre Syndrome patho 3. infection vaccine autoimmune ARF ABG's

GBS causes ARDS Phases MG causes

4. comprehensive head to toe diagnostic labs insertion-GI tube, cath temporary dressing splints to fractures Secondary survey P.E. Intervention decoricate posture ARF oxygenation 5. nonpurposeful, stereotyped, and repetitive behaviors that commonly accompany focal impaired awareness seizures (in the semiologic classification, they define automotor seizures). The behavior is inappropriate for the situation. Patients are usually amnestic to their automatisms. complex/automatism seizure seizure phase Prodomal Seizure phase post ictal tonic-clonic seizure (grand mal) 6. stereotactic pallidotomy- destroy a portion of the globus pallidus, and thereby, decrease patients' muscle rigidity from Parkinson's disease DBS-uses electrical stimulation to modulate these control centers deep to the surface of the brain, improving communication between brain cells. This helps to reduce symptoms such as tremor, slowness, and stiffness.

Parkinson's surgical treatment Heat exhaustion interventions Parkinson's lab tests Parkinson's 4 cardinal symptoms

7. CSF mahave low dopamine MRI or SPECT to rule out other brain conditions Parkinson's drug treatment MG non-surgical interventions Parkinson's lab tests ARF interventions 8. lack of meds, give a med and see if it helps Myasthenic crisis Cushing triad Myasthenia Gravis patho Non urgent triage 9. complete- no function below injury incomplete-some function below injury Spinal cord injury complete vs incomplete Spinal Cord Injury Intervention

Triage rules HEat stroke prehospital interventions

10. Tonic-clonic tonic clonic myoclonic atonic Multiple sclerosis patho Generalized Seizures types Seizure Diagnostic testing Severe hypothermia symptoms 11. could wait several hours and survive ex. rash strains and sprains colds simple fractures Non urgent triage ARF interventions Myasthenic crisis Vent care 12. ABC's peripheral pulses and cap refill hemmorage check Glascow coma scale spinal shock- loss of motor, reflexes

assess mobility/function assess bowel activity Spinal cord injury physical assessment Stroke Risk factors non modifiable Causes fo seizures secondary Heat stroke hospital interventions

13. thyroid function SPEP AChR antibodies chest xray/ct RNS EMG Tensilon test MuSK antibodies parkland formula MG lab diagosis ARF oxygenation MG causes 14. sudden rise in BP with Bradycardia profuse sweating above injury flushing of skin blurred/spots in vision nasal congestion severe, throbbing headache Clonic seizures Shock drugs

autonomic dyreflexia Autonomic Dysreflexia causes

15. Rapid ID-hemmy or ischy CT scan Glucose stick Give ateplase if ischy ICU frequent vitals Hemmy-prep for surgery Stroke Initial assessment Severe hypothermia symptoms Stroke emerency interventions Heat exhaustion interventions 16. dyspnea low O irritable confused tachycardia decreased loc headache drowsy GBS physcial assessment ARDS physical assessment Glascow coma scale scores Mass causualty triage tags

17. ulcers-PPI-dine H2 blocker prazole enteral feeding electrolyte replace Heat exhaustion interventions Frsotbite physical assessment Mass causualty triage tags Vent complications and prevention 18. sudden dyspnea sharp stabbing chest pain anxiety cough tychypnea crackles pleural friction rub s3 or s4 sounds diaphoresis fever decreased SaO Pneumothorax interventions Plasmaphersis watch out for ARDS Physcial Assessment P.E. physical assessment 19. prevent heat loss warm up no booze blankets supine space out meds withhold IV meds until core temp 86 or higher monitor for vfib

rewarm trunk P.E. Intervention Severe hypothermia symptoms autonomic dyreflexia Hypothermia interventions

20. abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight Increased ICP symproms MS Lab diagnostics decoricate posture ARDS Interventions 21. Preventative: Avonex Betaseron Copaxon Acute-steroids and baclofen Shock drugs MS Drugs Cushing triad ARF ABG's 22. distorted acetylcholine receptors

hyperplasia of thymus gland ARDS Phases GBS causes MG causes P.E. Surgery

23. tumor or trauma metabolic disroders acute alchohol withdrawl electrolyte imbalance fever stroke TBI substances heart disease Causes fo seizures secondary Stroke emerency interventions Severe hypothermia symptoms Causes of seizures Primary 24. idiopathic genetic factors Generalized Seizures types Causes of seizures Primary partial seizure types

Causes fo seizures secondary

25. thymectomy Anaphylaxis bee treatment MG non-surgical interventions P.E. physical assessment MG surgical intervention 26. tremor muscle rigidity bradykinesia or askinesia (slow or no movement) postural instability Parkinson's surgical treatment Parkinson's Physcial assessment Parkinson's 4 cardinal symptoms Parkinson's drug treatment 27. vagal nerve stimulation-prevents seizures by sending regular, mild pulses of electrical energy to the brain via the vagus nerve. It is sometimes referred to as a "pacemaker for the brain." A stimulator device is implanted under the skin in the chest. A wire from the device is wound around the vagus nerve in the neck. Brain resection/corpus callosotomy-palliative surgical procedure for the treatment of medically refractory epilepsy. In this procedure the corpus callosum is cut through in an effort to limit the spread of epileptic activity between the two halves of the brain. Seizure surgcial management seizure phase Prodomal

Left hemisphere stroke changes Parkinson's surgical treatment

28. myalgia headaches anaphylaxis asepetic meningitis IVIG complications Left hemisphere stroke changes GBS lab diagnosis Heat exhaustion symptoms 29. needs quick treatment, but not immediately life threatening ex. severe ab pain renal colic complex or multicple bruises displace or multiple fractures new onset respiratory infection (pneumonia) ARDS Phases Triage Urgent Decrebate posture Flail chest 30. decide who get a room when highest acuity gets a room first MG causes

Spinal cord injury complete vs incomplete Triage rules Vent bundle

31. increased work of breathing hypercapnea noisy respirations cyanosis pallor retractions sweating change in LOC lung sounds normal ARDS Physcial Assessment GBS lab diagnosis ARDS Interventions Severe hypothermia symptoms 32. age gender history race- native, black, latino Myasthenia Gravis patho Parkinson's 4 cardinal symptoms Stroke Risk factors non modifiable Multiple sclerosis patho

33. begins on both sides of the brain, but can start in one side and spread to the whole brain. A person loses consciousness, muscles stiffen, and jerking movements are seen. These types of seizures usually last 1 to 3 minutes and take longer for a person to recover. Difference between decerebrate and decorticate posturing seizure phase Prodomal Autonomic Dysreflexia causes tonic-clonic seizure (grand mal) 34. small handwriting freezing rigidity masked faces difficult chewing/swallowing orthostatic hypotension soft speech urinary incontinence Stroke Risk factors modifiable Parkinson's Physcial assessment Increased ICP interventions Spinal cord injury physical assessment 35. poor judgement lack of awareness visual deficits and neglect left sided weakness HEat stroke prehospital interventions Right hemisphere stroke changes

Heat exhaustion interventions Increased ICP interventions

36. fatigue stress overexertion temperatures Seizure Phases MS aggravators MG lab diagosis MS Lab diagnostics 37. within 3 - 4.5 hours of initial onset not a massive stroke over 2/3 of a hemisphere CT done glucose stick done/rule out hyperglycemia BP below 185/ Hypothermia interventions autonomic dyreflexia When to give ateplase P.E. Intervention 38. post infection, pregnancy anesthesia period of exacerbation temp weakness after vaccine, menstration, change in temp worsening of symptoms with repetitive movement drooping eyelids dysphagia voice weakens with use

MS physical assessment MG physcial assessment GBS physcial assessment Myoclonic seizures

39. shivering dysarthia (slurred speach) drunk diuresis Moderate hypothermia symptoms Stroke Initial assessment Myasthenia Gravis patho Mild hypothermia symptoms 40. brief shock-like jerks of a muscle or group of muscles. They occur in a variety of epilepsy syndromes that have different characteristics. During a myoclonic seizure, the person is usually awake and able to think clearly. Myoclonic seizures MS physical assessment Spinal cord injury complete vs incomplete Decrebate posture 41. life threatening ex. respiratory distress

chest pain with sweating stroke active hemmorhage unstable vital signs Triage Emergent Triage Urgent Spinal cord injury complete vs incomplete ARDS Interventions

42. body heat to rewarm prehospital hospital rapid rewarm in water bath opiod analgesics ibuprofen for inflammatory cascade elevate above heart after rewarming debridement of tissue in higher degree frostbite Frostbite interventions Frostbite degrees autonomic dyreflexia ARDS Physcial Assessment 43. B-balance E-Eyes F-face A-arms S-speech T-time Stroke Risk factors non modifiable Heat exhaustion symptoms

Seizure Diagnostic testing Stroke Initial assessment

44. It's the time from the first symptom to the end of the seizure activity. It is during this time that intense electrical activity is occurring in the brain. Some common signs of this phase include: Loss of awareness Memory lapse Felling confused Difficulty hearing Odd smells, sounds or tastes Difficulty speaking or saying strange words Twitching Loss of muscle control Repeated movements (such as lip smacking or chewing) Body convulsions Racing heart Trouble breathing Frostbite degrees Seizure surgcial management Tonic Seizure seizure phase ictal 45. muscles suddenly become limp. Part or all of the body may become limp Autonomic Dysreflexia causes Seizures (Epilepsy) ARF vent Atonic

46. often mistaken for each other, HD has choreiform or jerky movements Spinal cord injury complete vs incomplete Huntington's vs. Parkinson's Right hemisphere stroke changes Glascow coma scale scores 47. RRT elevate HOB O ABG's assess respiratory/cardiac status imaging anticoagulations IV fluids hypotension-norepi, dobutamine, nitroprusside MS Lab diagnostics P.E. Intervention Decrebate posture When to give ateplase 48. occurs after the active part of the seizure. This is the recovery stage and during this phase any physical after effects of the seizure are felt. The type of seizure and the part of the brain involved will determine how long it takes for a person to return to their usual self. Some common signs of this phase include: Confusion Lack of consciousness Tiredness (fatigue) Exhaustion Headache Loss of bladder or bowel control Fear and anxiety Frustration

Shame or embarrassment Thirst Nausea Sore muscles Weakness in parts of the body Injury (head, cuts, broken bones) Seizure Phases Seizure phase post ictal seizure phase ictal seizure phase Prodomal

49. body temp over 104 hot dry skin mental status changes:confusion, bizarre behaviors, anxiety, drunk, agitation, seizures, coma hypotension tachycardia tachypnea electrolyte imbalance decreased renal function abnormal clotting crackles Decrebate posture seizure phase Prodomal Seizures (Epilepsy) Heat stroke symptoms 50. too much meds Anaphylaxis bee treatment Non urgent triage

Cushing triad Cholinergic crisis

51. epi then O MG surgical intervention Heat exhaustion symptoms ARDS physical assessment Anaphylaxis bee treatment 52. Seizure lasting longer than 5 minutes or repeated seizures over 30 min. Medical emergency give a pam IV phenytoin Status epilepticus Myoclonic seizures Rule of nine Seizures (Epilepsy) 53. HOB above 30 oral care q 2 ulcer prophylaxis pulmonary hygiene Seizure Phases MG causes

Vent bundle P.E. Surgery

54. vent/intubation-PEEP assess and suction frequently prone positioning antibiotics prn conservative fluid therapy nutrition asap GBS lab diagnosis P.E. Intervention parkland formula ARDS Interventions 55. rest in a cool place cold pack on neck, ab, groin soak in cool water rehydrate with electrolytes Stroke emerency interventions Parkinson's 4 cardinal symptoms Heat exhaustion interventions Plasmaphersis watch out for 56. life-threatening medical condition that occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall. Two of the symptoms of flail chest are chest pain and shortness of breath.

ARDS Phases Flail chest seizure phase Prodomal Vent care

57. HTN Diabetes hyperlipidemia obestiy sedentary lifestyle oral contraceptive use smoking excessive alcohol atrial fibrillation Severe hypothermia symptoms Stroke Initial assessment Stroke Risk factors modifiable Stroke Risk factors non modifiable 58. cool patietn down remove clothing cold water on body fan ice packs HEat stroke prehospital interventions Bee sting treatment Frsotbite physical assessment

Left hemisphere stroke changes

59. HOB elevate O2 over 94% head neutral position no sudden movements no cluster of cares low stimulation Increased ICP interventions MG non-surgical interventions Multiple sclerosis patho Severe hypothermia symptoms 60. sepsis burns pancreatitis trauma transfusion TRALI SIRS P.E. Surgery GBS causes Cushing triad ARDS Causes 61. oxygen doesn't get into lungs, airway issue ARF interventions ARDS Causes

Shock treatment ARF vent

62. respiratory assessment suctioning physiotherapy activity after meds protect eyes Heat exhaustion interventions ARDS physical assessment Stroke emerency interventions MG non-surgical interventions 63. temporary stroke that leaves no mark behind TIA patho MS Drugs Types of MG Spinal shock 64. parethsesias muscle weakness loss of reflexes in arms/legs low BP/ poor BP control muscle weakness without muscle atrophy uncoordinated movements blurred vision palpations decreased respiratory function

When to give ateplase ARDS Physcial Assessment GBS physcial assessment Parkinson's drug treatment

65. superficial cold injury pain, numbness, waxy no tissue damage Frostnip ARF vent ARDS Causes ARF ABG's 66. ABCDE Triage Urgent Primary survey TIA symptoms Simple seizure 67. O2 keep PaO2 above 60 bronchodilators roids vent diruetics PRN