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NR 325 FINAL EXAM STUDY GUIDE 2024/LATEST UPDATE EXAM QUESTIONS WITH CORRECT DETAILED AND WELL ELABORATED ANSWERS /A+ GRADE
Typology: Exams
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gauze pad or towel and observe drainage. Within minutes, blood moves into the center and a yellowish ring will encircle the blood if CSF is present. Note color appearance and amount of leakage. False positive results could occur. Major potential complications of skull fracture= intracranial infections, hematoma, meningeal and brain tissue damaged. Also note if basilar skull fracture is suspected NG tube or oral gastric tube should be inserted under fluoroscopy. (pg. 1369) **Intracranial Pressure Manifestations: (ATI pg. 14)Monitor for these manifestations **listed in Question 21. ****
*C6 Injury= Partial paralysis of the hands and arms and lower body *T6 Injury=Paraplegia=Paralysis below the chest Any injury above T6, Patient will have bradycardia & periperihal vasodilation=hypotension. *L1 Injury= Paralegia=Paralysis below the waist. Injury above L1/L2 will convert to spastic muscle tone after neuro shock ( upper motor neuron injuries). Injury below L1/L2 convert to a flaccid type of paralysis *(Lower motor neuron injuries)
Autonomic dysreflexia: ATI pg. 16 Nursing Interventions: encourage active ROM exercises if possible, passive if patient lacks motor functions. Monitor I/O, Maintain fluids to prevent urinary calculi and bladder infections. Prevent skin breakdown, can use special bed and equipment for this. Monitor bowel sounds (ileus could develop). Change position every 2 hours (can not feel pain or prolonged pressure). Teach about sexual functions. Quad patients/upper motor neuron=usually capable of reflexogenic erections (erections secondary to manual manipulation) Ejaculation coordination with emission might not occur. Lower neuron injuries less likely to have reflexogenic erections but might be able to have combo of reflexogenic and psychogenic erections (sexual thoughts/images). Bowel: Use daily stool softeners or bulk-forming laxatives. Bowel movement can be stimulated daily or everyother day by bisacodyl suppository or digital(finger) stimulation. ** Use digital stimulation cautiously to avoid provoking a vagal response, which leads to bradycardia and syncope.
Questions 7 lists Bladder interventions. Patient can experience two types of shock : spinal shock: decreased reflexes, loss of sensation and flaccid paralysis below the level of injury, can last days to month and may mask postinjury neurological function. Neurogenic shock : contrast to spinal shock due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. Usually associated with cervical or high thoracic injury. ** Nursing interventions for neurogenic shock : Monitor for hypotension, dependent edema, and loss of temperature regulation (common manifestations). When Patient is upright, patient will experience postural hypotension. When transferring a client to a wheelchair: slow and in stages · Raise the head of the bed and be ready to lower the angle if patient gets dizzy. Transfer the client into a reclining wheelchair with back of the wheelchair reclined. Be ready to lock and lean the wheelchair back onto knee to a fully reclining position if the patient reports dizziness after transfer. Do not return patient to the bed · Monitor for manifestations of thrombophlebitis (swelling of extremity, absent/decreased pulses, and areas of warm and tenderness) Patient may need anticoagulants to prevent development of lower extremity thrombi.
possible vomiting. Positive signs: Abdominal pain that is most intense at McBurney’s point. Rebound tenderness and abdominal rigidity, elevated white blood cell count. Surgical Interventions : Appendectomy Pre-op: **(removal of NONruptured appendix)..Laparoscopic surgery, Administer IV fluid replacement as prescribed, Administer antibiotic. **(removal of Ruptured)..Laparoscopic OR open surgery. Administer electrolyte and fluid replacement as prescribed, place NG tube for decompression, administer antibiotics. Post-op **(NONruptured appendix)..assess respiratory status, maintain airway, provide O2 as prescribed, vitals, administer analgesics for pain, assess surgical site or any abnormalities, assess bowel sounds and bowel function. **(Ruptured appendix) Same as nonruptured PLUS; Maintain NPO status, maintain NG tube to low continuous suction. Provide wound irrigations with antibacterial solution or saline-soaked gauze as prescribed. Provide drain care. Assess for peritonitis (fever, sudden increase in pain, irritability, rigid abdomen, abdominal distention, tachycardia, rapid shallow breathing, pallor, chills.
problems) D ementia, dehydration E lectrolyte imbalances, emotional stress L ung, liver, heart, kidney, brain I nfection, intensive care unit R x drugs I njury, immobility U ntreated pain, unfamiliar environment M etabolic disorders Dementia (Chronic, slow progression): syndrome characterized by dysfunction or loss of memory, orientation, attention, language, judgment, and reasoning. Personality changes and behavioral problems such agitation, delusions, and hallucinations may occur. DX when two or more brain functions are significantly impaired such as memory loss, language skills etc. Sleeping during day, and awakening at night. Confusion: Can be acute/chronic, Less extreme than delirium. Slurring words, long pauses in speech, abnormal or incoherent speech, lack of awareness of location or time, forgetting tasks being performed while performing it. Sudden changes in emotion such as sudden agitation.
Dementia (Chronic) Delirium (Acute)
Onset Usually Insidious Rapid, often at night Progression Slow Abrupt Duration Years (usually 8 - 20 years) Hours to days to weeks Thinking Difficulty with abstract thinking, impaired judgment, words difficult to find Disorganized, distorted. Slow oe accelerated incoherent speech. Perception Misperceptions often present. Delusions and hallucinations Distorted. Delusions and hallucinations Pyscho-motor behavior May pace or be hyper active. As disease progresses, may not be able to perform tasks or movements when asked. Variable. Can be hyperactive or hypoactive or mixed. Sleep-wake cycle Sleeps during day. Frequent awakenings at night. Fragmented sleep. Disturbed sleep cycle. Reversed sleep cycle
pain; bradycardia, hypotension, dysrhythmias, slow thought processes and speech, hypoventilation, pleural effusion, thickening of the skin, thinning of hair on the eyebrows, dry, flaky skin, swelling in face, hands, and feet (myxedema [non-pitting, mucinous edema]), decreased acuity of taste and smell, hoarse, raspy speech, abnormal menstrual periods (menorrhagia/amenorrhea), decreased libido An increased TSH indicates primary hypothyroidism due to thyroid dysfunction or thyroiditis. Treatment: ● Thyroid hormone replacement (e.g., levothyroxine) ○ Nursing considerations ■ Administer thyroid hormone replacement therapy. ■ Monitor for cardiovascular compromise (e.g., chest pain, palpitations, rapid heart rate, shortness of breath). ● Monitor thyroid hormone levels and adjust dosage (if needed) ● Nutritional therapy to promote weight loss ● Patient and caregiver teaching Myxedema (hypothyroidism crisis situation): Myxedema coma is a life-threatening condition that occurs when hypothyroidism is untreated or when a stressor (e.g., acute illness, surgery, chemotherapy, discontinuing thyroid replacement therapy, or use of sedatives/opioids) affects a client who has hypothyroidism. S/S: Respiratory failure; Hypotension; Hypothermia; Bradycardia, dysrhythmia; Hyponatremia; Hypoglycemia; Coma Nursing Considerations: ● Maintain airway patency with ventilatory support if necessary.
● Provide continuous ECG monitoring. ● Monitor ABGs to detect hypoxia, hypercapnia, respiratory acidosis. ● Monitor mental status. ● Cover the client with warm blankets. ● Monitor body temperature hourly until stable. ● Replace fluid with 0.9% sodium chloride IV. ● Replace thyroid hormone by administering large doses of levothyroxine IV bolus. ● Monitor vital signs because rapid correction of hypothyroidism can cause adverse cardiac effects. ● Monitor I&O and daily weights. With treatment, urine output should increase, and body weight should decrease. Failure to do so should be reported to the provider. ● Treat hypoglycemia with glucose. ● Administer corticosteroids. ● Initiate aspiration precautions ● Check for possible sources of infection (blood, sputum, urine) that might have precipitated the coma. Treat any underlying illness. Hyperthyroidism: (Grave’s disease) Graves' disease is exophthalmos, a protrusion of the eyeballs from the orbits that is usually bilateral S/S: nervousness, irritability, hyperactivity, emotional lability, decreased attention span, cries or laughs without cause, change in mental or emotional status, weakness, easy fatigability, exercise
intolerance, muscle weakness, heat intolerance, weight change (usually loss) and increased appetite, insomnia and interrupted sleep, frequent stools and diarrhea, menstrual irregularities (amenorrhea or decreased menstrual flow) and decreased fertility, libido initially increased in both men and women, followed by a decrease as the condition progresses, warm, sweaty, flushed skin with velvety-smooth texture, hair thins, and develops a fine, soft, silky texture, tremor, hyperkinesia, hyperreflexia, exophthalmos (graves’ disease only) due to edema in the extraocular muscles and increased fatty tissue behind the eye, blurred or double vision and tiring of eyes due to pressure on the optic nerve, photophobia (sensitivity to light), excessive tearing and bloodshot appearance of eyes, pretibial myxedema: dry waxy swelling of the front surfaces of the lower legs that resembles benign tumors (graves’ disease only), vision changes ( eyelid retraction (lag): movement of the eyelid is delayed when the eye moves downward; globe (eyeball) lag: upper eyelid pulls back faster than the eyeball when the client gazes upward ), hair thinning or loss, goiter, bruit over the thyroid gland, elevated systolic blood pressure and widened pulse pressure, tachycardia, palpitations, and dysrhythmias, dyspnea, findings in older adult clients are often more subtle than those in younger clients (Occasionally, an older adult client who has hyperthyroidism will demonstrate apathy or withdrawal instead of the more typical hypermetabolic state. Older adult clients who have hyperthyroidism often present with heart failure, angina, and atrial fibrillation.) A decreased value indicates hyperthyroidism (graves’ disease) or secondary hypothyroidism (due to pituitary or hypothalamus dysfunction). Treatment: ● Drug Therapy ○ Thionamides are used to treat Graves’ disease, as an adjunct to radioactive iodine therapy, to decrease hormone levels in preparation for surgery, and to treat
thyrotoxicosis (ATI p. 507). ■ methimazole (Tapazole) ■ Propylthiouracil ○ Iodine (SSKI) ■ Lugol’s solution is a nonradioactive 5% elemental iodine in 10% potassium iodine that inhibits the release of thyroid hormone. ● β-Adrenergic receptor blockers treat sympathetic nervous system effects (tachycardia, palpitations). These medications counteract the effects of increased thyroid hormones but do not alter the levels of the hormones (ATI p. 507). ○ propranolol (Inderal) ○ atenolol (Tenormin) or metoprolol (Toprol) ● Radiation Therapy ○ Radioactive iodine is taken up by the thyroid and destroys some of the hormone- producing cells (131 I). ■ One dose can be sufficient, but a second or third dose might be needed. ■ The degree of thyroid destruction varies and can require lifelong thyroid replacement. ● Surgical Therapy ○ Subtotal thyroidectomy can be performed for the treatment of hyperthyroidism when medication therapy fails or radiation therapy is contraindicated. It can also be used to correct diffuse goiter and thyroid cancer. After a subtotal thyroidectomy, the remaining thyroid tissue usually supplies enough thyroid hormone for normal function (ATI). ○ Total thyroidectomy is performed, the client will need thyroid hormone replacement
therapy. ● Nutritional Therapy ○ High-calorie, high-protein diet ○ Frequent meals Thyroid storm/crisis results from a sudden surge of large amounts of thyroid hormones into the bloodstream, causing an even greater increase in body metabolism. This is a medical emergency with a high mortality rate (ATI). ● Nursing considerations (ATI): ○ Maintain a patent airway. ○ Provide continuous cardiac monitoring for dysrhythmias. ○ Administer acetaminophen to decrease temperature.! Salicylate antipyretics (aspirin) are contraindicated because they release thyroxine from protein- binding sites and increase free thyroxine levels. ○ Provide cool sponge baths, or apply ice packs to decrease fever. If fever continues, obtain a prescription for a cooling blanket for hyperthermia. ○ Administer thionamides (methimazole or propylthiouracil) to prevent further synthesis and release of thyroid hormones. ○ Administer sodium iodide as prescribed, 1 hr after administering thionamide medication. ○ Administer beta-adrenergic blocking agents, such as propranolol, to block sympathetic nervous system effects. ○ Administer glucocorticoids if adrenal insufficiency is suspected or to treat shock. ○ Administer IV fluids to provide adequate hydration and prevent vascular collapse. Fluid volume deficit can occur due to increased fluid excretion by the kidneys or
excessive diaphoresis. Monitor intake and output hourly to prevent fluid overload or inadequate replacement. ○ Administer supplemental O2 to meet increased oxygen demands. System Cushing’s Disease/ Syndrome (too much) Addison's Disease (too little) Glucocorticoids General appearanc e Truncal obesity, thin extremities, rounding of face (moon face), fat deposits on back of neck and shoulders (buffalo hump) (Fig. 49 - 11 ). Weight loss, emaciation.
Integumen tary Thin, fragile skin, purplish red striae (Fig. 49- 12 ). Petechial hemorrhages, bruises. Florid cheeks (plethora), acne, poor wound healing. Bronzed or smoky hyperpigmentation of face, neck, hands (especially creases) (Fig. 49 - 13 ), buccal membranes, nipples, genitalia, and scars (if pituitary function normal). Vitiligo, alopecia. Cardiovas cular Hypervolemia, hypertension, edema of lower extremities. Hypotension, tendency to develop refractory shock, vasodilation. Gastrointe stinal Increase in secretion of pepsin and HCl acid, risk of peptic ulcer disease, anorexia. Anorexia, nausea and vomiting, cramping abdominal pain, diarrhea. Renal/urin ary Glycosuria, hypercalciuria, risk for kidney stones. Musculos keletal Muscle wasting in extremities, fatigue, osteoporosis, awkward gait, back pain, weakness, compression fractures. Fatigue. Immune Inhibition of immune response, suppression of allergic response. Tendency for coexisting autoimmune diseases. Metabolic Hyperglycemia, negative nitrogen balance, dyslipidemia. Hyponatremia, insulin sensitivity, fever. Emotional Euphoria, irritability, depression, insomnia, anxiety. Depression, exhaustion or irritability, confusion, delusions.
Mineralocorticoids Fluid and electrolyte s Marked sodium and water retention, edema, marked hypokalemia, alkalosis. Sodium loss, decreased volume of extracellular fluid, hyperkalemia, salt craving. Cardiovas cular Hypertension, hypervolemia. Hypovolemia, tendency toward shock, decreased cardiac output. Androgens Integumen tary Hirsutism, acne, hyperpigmentation. Decreased axillary and pubic hair (in women). Reproduct ive Women: Menstrual irregularities and enlargement of clitoris Men: Gynecomastia and testicular atrophy. Women: Decreased libido in women Men: No effect in men. Musculos keletal Muscle wasting and weakness. Decrease in muscle size and tone. Cushing’s Treatment: Treatment depends on the cause. For Cushing’s syndrome, tapering off
glucocorticoids and managing symptoms are necessary. ● Pituitary Adenoma ○ Transsphenoidal resection ○ Radiation therapy ● Adrenocortical Adenoma, Carcinoma, or Hyperplasia ○ Adrenalectomy (open or laparoscopic) removal of adrenal gland ○ Drug therapy (e.g., ketoconazole , aminoglutethimide, mitotane , mifepristone [Korlym], hydrocortisone ) ● Ectopic ACTH-Secreting Tumor ○ Treatment of the tumor (surgical removal or radiation) ● Exogenous Corticosteroid Therapy ○ Discontinue or alter the dose of exogenous corticosteroids Addison’s Disease Treatment: ● Daily glucocorticoid (e.g., prednisone, hydrocortisone, and cortisone) replacement (two thirds on awakening in morning, one third in late afternoon) ○ Nursing considerations (ATI p.524) ■ Monitor weight, blood pressure, and electrolytes. ■ Increase dosage during periods of stress or illness if necessary. ■ Taper dose if discontinuing to avoid acute adrenal insufficiency. ■ Administer with food to reduce gastric effects ■ Increased doses of glucocorticoid for stress situations (e.g., surgery, hospitalization) ● Daily mineralocorticoid (fludrocortisone) in morning ○ Nursing considerations
■ Monitor weight, blood pressure, and electrolytes. ■ Hypertension is a potential adverse effect. ■ Dosage might need to be increased during periods of stress or illness. ● Increased salt in the diet ● Androgen replacement with dehydroepiandrosterone (DHEA) for women ● Salt additives for excess heat or humidity Adrenal crisis also known as Addisonian crisis (acute adrenal insufficiency) Sudden drop in corticosteroids is due to sudden tumor removal; stress of illness, trauma, surgery, or dehydration; or abrupt withdrawal of steroid medication (ATI). ● Nursing actions ○ Indications include hypotension, hypoglycemia, hyperkalemia, abdominal pain, weakness, and weight loss. ○ Administration of glucocorticoids treats acute adrenal insufficiency. ○ Administer insulin with dextrose, a potassium-binding and - excreting resin (sodium polystyrene sulfonate), or loop or thiazide diuretics to treat hyperkalemia. ○ Administer glucagon or glucose via IV bolus to treat hypoglycemia. ○ Monitor vital signs and glucose levels. ○ Monitor ECG.
● Initiate bowel and bladder program based on a set schedule ● Encourage the client and family to participate in an AD support group ● Provide a safe environment ○ Frequent monitoring/visual checks ○ Keep client from stairs, elevators, exits ○ Remove or secure dangerous items in the clients environment ● Provide frequent walks to reduce wandering ● Maintain a sleeping schedule, and monitor for irregular sleeping patterns ● Provide verbal and nonverbal ways to communicate with the client ● Offer snacks or finger foods if the client is unable to sit for long periods of time ● Check skin weekly for breakdown. ● Provide cognitive stimulation ○ Offer varied environmental stimulations, such as walks, music, or craft activities ○ Keep structured environment and introduce change gradually. ○ Use calendar to assist with orientation ○ Use short directions when explaining an activity or care the client needs such as bath ○ Be consistent and repetitive ○ Use therapeutic touch ● Provide memory training ○ Reminisce with the client about the past ○ Use memory techniques such as making lists and rehearsing ○ Stimulate memory by repeating the client’s last statement ● Avoid overstimulation (keep noise and clutter to a minimum)
● Promote consistency by placing commonly used objects in the same location and using a routine schedule ○ Reality orientation (early stages) ○ Easily viewed clock and single-day calendar ○ Pictures of family and pets ○ Frequent reorientation to time, place, and person ● Validation therapy (later stages) ○ Acknowledge the client’s feelings ○ Don’t argue with the client ○ Reinforce and use repetitive actions or ideas cautiously ● Promote self-care as long as possible. Assist with activities of daily liviing as appropriate. ● Speak directly to the client in short, concise sentences. ● Reduce agitation (calm, redirecting statements, provide diversion) ● Provide routine toileting schedule. Dementia ● Acknowledge the client’s feelings ● Provide safe environment ● Develop a comprehensive plan of care with the family, client, and interprofessional team Delirium (S&S: agitation, hallucinations, sleepiness, lethargy) ● Providing a therapeutic environment (reduce noise, adequate lighting, maintain consistency and continuity of nursing staff, avoid relocation or transfer if possible, orient to time place and self, soothing environment)
● Orienting the patient frequently ● Anticipating the patient’s needs(assess pain and provide analgesia as needed, monitor vitals, promote hydration, providing orientation, encouraging mobility, providing sensory aids as appropriate) ● Ensuring that hearing aids and eyeglasses are available for patients who use them ● Observing the patient’s response to medications ● Check lab tests
Lower motor neuron loss have flaccid bladder( intermittent catheterization or crede's method). Daily use of stool softeners or bisacodyl suppository or digital stimulation. Upper motor neuron injury: spastic bladder - condom catheters. Micturition reflex by tugging pubic hair, indwelling urinary catheter.
● Elevated ALT, AST, ALP, bilirubin, HAV antibodies, IgM present, IgG present ● Immunization or immunoglobulin (older than 40, younger than 12, liver disease, allergic or immunocompromised Hepatitis B - Blood (Unprotected sex, infants born, infected blood, substance abuse) ● Elevated ALT, AST, ALP Bilirubin, HBsAg present, anti-HBs present , Anti-HBc present, IGM, HBeAg, anti HBe and HBsAb present. ● No medications only supportive care, antivirals ends in “vir”, interferon alpha-2b, peginterferon alpha - 2a, lamivudine and telbivudine Hepatitis C - Blood (Sex, blood, organ transplants, tattoo equipment, needlesticks) ● Elevated ALT, AST, ALP, bilirubin, Anti HCV present, EIA, CIA,RIBA, PCR present. ● Combination therapy of ribavirin and peginterferon alpha 2a Hepatitis D - Coinfection with HBV (substance abuse, sex) ● Identification of Intrahepatic delta antigen & anti-HDV ● None Hepatitis E - Fecal/oral (Contaminated food or water with fecal waste) ● Anti - HEV present ● None, just supportive care Symptoms - flu like (fatigue, decreased appetite, nausea,abdominal pain and joint pain) Fever, vomiting, dark colored urine, clay colored stool and jaundice. Diagnosis : liver biopsy and lab results Education/ Care: contact precautions, provide high calorie, low to moderate fat/protein, small frequent meals, avoid OTC medications, avoid alcohol, limit physical activity, avoid sexual intercourse, use proper hand hygiene. Complications : liver failure , cancer, chronic hepatitis, cirrhosis and fulminant hepatitis
( extremely dangerous fatal form of viral hepatitis)
side first , adaptive aids, support leaning side, support shoulder while in bed with a sling to prevent dislocation & emotional support.
● Promote fiber intake (beans, vegetables, oats, whole grains) to improve carbohydrate metabolism and lower cholesterol ● Recommendation for fiber intake includes at least 14g per 1,000 calories Protein: ● Protein from meats, eggs, fish, nuts, beans, and soy products should comprise 15% to 20% of total caloric intake. Reduce protein intake if needed in clients who have diabetes and kidney failure