Multidimensional Care IV Exam 3, Exams of Nursing

Download Multidimensional Care IV Exam 3 and more Exams Nursing in PDF only on Docsity! 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. 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 O2 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 SaO2 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 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 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 Cushing triad Cholinergic crisis 51. epi then O2 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 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 upright position energy-conservation parkland formula GBS interventions ARF interventions ARDS Interventions 68. first-hyperemia, edema second-clear to milky fluid filled blisters iwth partial thickness skin necrosis thrird-small blisters with dark fluid affected body part cool numb blue or red no blanch fourth no blisters or edem, cold, bloodless gangrene can develop Simple seizure Frostbite degrees GBS lab diagnosis ARF interventions 69. flu-like headache heavy sweating Anaphylaxis bee treatment Heat exhaustion symptoms Seizure Diagnostic testing ARDS Physcial Assessment 70. O2, intiibation PRN 1 large bore IV NS cooled preferably cooling blanket rectal temp q15 indwelling urinary cath frequent vitals labs-electrolytes, cardiac enzymes, liver enzymes, stop shivering stop cooling when body is at 102 HEat stroke prehospital interventions Heat stroke hospital interventions tonic-clonic seizure (grand mal) Heat exhaustion interventions 71. air gets into lungs but not into blood, right to left shunting of blood in pulmonary vessels (ARDS) Secondary survey decoricate posture ARF oxygenation Cushing triad 72. bring to floor roll on side clear objects away observe and documetn loosen clothing if restrictive oral suction in mouth PRN Seizure interventions prevent injury decoricate posture Clonic seizures Decrebate posture parkland formula 79. mild and stable-none chest tube needle throacostomy immediate if tension pain control pulmonary hygeine Heat exhaustion interventions Plasmaphersis watch out for Pneumothorax interventions Parkinson's Physcial assessment 80. gas exchange is reduced due to ventilation or oxygenation or both issues ARF ARF interventions Atonic ARF vent 81. During the this stage some people can tell when a seizure is on its way. They may notice some early signs hours or even days before the seizure starts. Not all people experience this stage. Some common signs can include: Mood changes Anxiety Feeling lightheaded Difficulty sleeping Difficulty staying focused Behaviour changes. Heat stroke symptoms Seizure phase post ictal Seizure Phases seizure phase Prodomal 82. language deficits anxiety/depression right sided weakness Guillian Barre Syndrome patho Right hemisphere stroke changes Left hemisphere stroke changes Vent complications and prevention 83. seizuer-sudden uncontrolled electrical discharge of neurons epilepsy-2 or more seizures Secondary survey Non urgent triage decoricate posture Seizures (Epilepsy) 84. 4xburned areaxkg 1/2 in first 8 hours other half in next 16 from burned time not treatment time. neurogenic shock parkland formula Decrebate posture Clonic seizures 85. visual-blurred vision, diplopia, blindness in one eye, tunnel vision mobility-unilateral weakness and ataxia sensory-unilateral numbness speech-aphasia, dysarthria Tonic Seizure Shock drugs ARDS Phases TIA symptoms 86. autoimmune disease muscle weakness Seizure Diagnostic testing Myasthenia Gravis patho partial seizure types autonomic dyreflexia 87. SBP + 2(DBP)/3 Pneumothorax interventions 93. exudative-early dyspnea and tachycardia fibroproliferative- lung injury, pulmonary HTN, fibrosis, reduced gas exchange, MODS REsolution after 14 days die or recover ARDS Phases Shock drugs ARDS Physcial Assessment Vent care 94. acute inflammation of axons or myelin of PNS Guillian Barre Syndrome patho Multiple sclerosis patho Myasthenic crisis Heat exhaustion interventions 95. Decorticate posturing — a sign of severe damage to the brain — is a specific type of involuntary abnormal posturing of a person. ... decerebrate posturing, better where arms and legs are straight and rigid, toes are pointed downward, and head is arched backward. Parkinson's surgical treatment Increased ICP symproms Difference between decerebrate and decorticate posturing Heat stroke hospital interventions 96. choliesterase inhibitors-pyridostigmine immunosuppressant-methotrexate, rituximab, steroids IVIG for acute treatment MG drug intervention autonomic dyreflexia ARDS Interventions P.E. Intervention 97. sign of increased ICP -Widening of pulse pressure, -Slowing HR -severe HTN Vent bundle Cushing triad Bee sting treatment ARF oxygenation 98. A simple partial seizure will affect only one area of your brain. It doesn't cause you to lose consciousness Simple seizure decoricate posture ARF interventions parkland formula 99. sinement-carbadopa/levadopa (stimulate dopamine receptors) COMT Inhibitor-Entacapone (prolong action of levodopa) MAOIS-rasagiline mesylate (increase dopamine concentration) Dopamine receptor agonists- Bromocriptine mesylate (promote dopamine release) Antiviral-amantadine Pneumothorax interventions Parkinson's 4 cardinal symptoms Parkinson's drug treatment Hypothermia interventions 100. a sudden stiffness or tension in the muscles of the arms, legs or trunk. The stiffness lasts about 20 seconds and is most likely to happen during sleep. Tonic seizures that occur while the person is standing may cause them to fall. After the seizure, the person may feel tired or confused Tonic Seizure TIA symptoms tonic-clonic seizure (grand mal) Spinal shock 101. airway management (especially above T-6) Vent PRN manage secretions cough assist (quad cough) maintain hydration spinal immobilization skin integrity prevent DVT manage spasicity- tizadidine, baclofen Frostbite interventions Cushing triad Shock drugs P.E. Surgery ARDS Phases 108. decreased LOC restlessness, irritability and confusion headache nausea/vomiting change in speech pupillary changes ataxia seizuers cushing triad posturing GBS physcial assessment Increased ICP symproms MS Lab diagnostics Parkinson's lab tests 109. muscle weakness and spasticity fatigue intention tremor dysmetria (inability to direct movement) Numbnesss ataxia-decreased coordination dysarthria dysphagia diplopia nystagmus tinitius/hearing loss cognitive changes depression ARDS physical assessment MS physical assessment GBS physcial assessment P.E. physical assessment 110. temp over 104 emergency Cholinergic crisis HEat stroke prehospital interventions GBS interventions Heat stroke patho 111. determine surface area of body head=9 each arm=9 each leg=18 torso=36 Seizure Phases MG causes neurogenic shock Rule of nine 112. PaO2 less than 60 SaO2 is less than 90 TIA patho ARDS Causes Vent bundle ARF ABG's 113. prodromal, aural, ictal, postictal Seizure phase post ictal Seizure Phases Simple seizure Seizure Diagnostic testing 114. demyelination and axonal nerve damage Multiple sclerosis patho partial seizure types Stroke Initial assessment Generalized Seizures types 115. end-tidal CO2 and x-ray verify tube placement on vent Heat stroke patho