NR341 Complex Adult Health Final Study Guide, Exams of Nursing

Download NR341 Complex Adult Health Final Study Guide and more Exams Nursing in PDF only on Docsity! 1 [Date] 2 NR341 Complex Adult Health Final Study Guide. Questions And Answers Latest Update 2023. What are symptoms of a stroke, brain attack, and CVA? -Correct Answer= *Headache *Confusion *Seizures *Incontinence *Vomiting *Disorientation *Diplopia *Ptosis *Hypertension *Apraxia *Decreased Neuromuscular control *Memory Impairment *Aphasia (L Hemisphere for CVA) *Decreased cough/Swallow Reflex *Agnosia (Decr. Sensory interpretation) *Hemiparesis/hemiplegia *Emotional Liability *Loss of corneal reflex *Homonymous *Hemianopsia *Spatial-Perceptual Defects What are symptoms of Transient Ischemic Attacks (TIA)? -Correct Answer= *Confusion *Vertigo *Dysarthria *Transient Hemiparesis *Temporary Vision Changes *Typically lasts less than 1 hours 2 [Date] 2 What are Focal Neurological symptoms? -Correct Answer= *Paralysis *Sensory Loss *Language Disorder *Reflex Changes What are the 3 steps to stroke recognition? -Correct Answer= 1. Ask person to smile and stick out tongue 2. Ask person to make a complete sentence 3. Ask person to raise both arms What are symptoms of CVA? -Correct Answer= *Hypo/Hypertonia *Perceptual Defects *Apraxia *Loss of voluntary movement on one side *Decreased Neuromuscular Control *Communication Issues *Emotional Lability *Impaired judgement and memory What are causes of CVA? -Correct Answer= *Atherosclerosis *Thrombosis *Embolism *Cerebral hemorrhage (trauma/tissue damage). What are symptoms of Right Hemisphere CVA? -Correct Answer= *Left sided weakness/Paralyzed left side hemiplegia *Perceptual Defects (Vulnerable to Accidents) *Spatial-Perceptual Deficits *Tends to minimize problems *Short attention span *Visual field deficits *Impaired judgment *Impulsive *Impaired time concept 5 [Date] 2 *Severe HTN *Bradycardia *Irregular respiration *Restlessness/confusion What are nursing interventions for increased ICP? -Correct Answer= *Neuro evals *Airway Patency *Semi-Fowlers position *GCS exams *Change positions slowly *Suction *Maintain hydration *SZ precautions *Monitor I&O's *Avoid coughing, sneezing, and valsalva maneuver *Prevent Aspiration *Calm/Quite environment *Early mobility *Change positions Q2 hours What are complications of increased ICP? -Correct Answer= *Herniation *Inadequate Cerebral Perfusion *SIADH *Diabetes Insipidus *Infection What are treatments for increased ICP? -Correct Answer= *ICP Monitoring (Ventriculostomy, GCS) *Cerebral oxygenation Monitoring (LICOX) *Hypertonic Saline IVs *Medications -Osmotic Diuretics -Corticosteriods -Anti-seizure Drugs What are diagnostics for increased ICP? -Correct Answer= *CT Scan 6 [Date] 2 *MRI *PET *EEG *Angiography *Brain tissue oxygenation Catheter- LICOX *Transcranial Doppler Studies *Evoked Potential Studies Management of increased ICP includes? -Correct Answer= *Identification of patients risks *Initiation of ICP monitoring if indicated *Airway maintenance and ventilation *Oxygenation and low normal PaCO2 *Fluid balance to maintain cerebral perfusion *Avoiding positions that increase ICP *Sedation and decreased external stimulation *Osmotic and loop diuretics administration *Temperature maintenance *Blood glucose Control *Pain management and stool softeners Ways to avoid increased ICP -Correct Answer= *Prevent increased CO2 (mechanical ventilation, PaCo2 26-30) *Mechanical ventilation (controls CO2) *Keep neck mid-line, neutral position *HOB at 30 degrees *Hyperoxygenate prior to suctioning *Suppress cough *Prevent shivering *Control body temp *Maintain CPP What medications are used for increased ICP? -Correct Answer= *Corticosteriods 7 [Date] 2 (brain) *Oxygen *BP meds (Labetalol & Nicardipine) *IV fluids (NS/Hypertonic) *Diuretics (Mannitol, Furosemide) What is Cushing's triad? -Correct Answer= *HTN with widened pulse pressure *Bradycardia *Irregular breathing (Cheyene) What is Cerebral Perfusion Pressure -Correct Answer= *CPP = MAP - ICP *60-100mg HH *Determines Cerebral blood flow (CBF) *Less than 50 = ischemia & neuronal death *Raising MAP increases CPP *Raising ICP decreases CPP What is Decorticate Posturing? -Correct Answer= Decorticate Posturing *Flexor Posturing *Damage to the cervical spinal tract/cerebral hemisphere *Suggests cerebral cortex involvement *To the core *Hands turned inward *Arms folded in *Feet and legs extended out What is Decerebrate Posturing? -Correct Answer= Decerebrate Posturing -Extensor Posturing -Damage to brain stem -Arms extended -Wrist rotated -Legs extended -Feet internally rotated 10 [Date] 2 What are triggers to contact Organ Donation Coordinator? -Correct Answer= *All patients with severe brain injury requiring mechanical ventilation ~Call Immediately~ *Brain death testing is being discussed *Discussion of ventilation/vasopressor withdrawal *End-of-life/comfort care measures are being discussed ~Call within 1 Hour~ *GCS score below 5 and ventilated *Cardiac Death Indications your patient is a donor candidate? -Correct Answer= *Brain Dead *Circulatory Death *Living Donor What is brain death? -Correct Answer= *Absent cerebral & brain stem function associated with non- survivable head injury *Verified with -Apnea test -EEG -Cerebral angiography -Radionuclide cerebral perfusion scan What happens with circulatory death? -Correct Answer= Once criteria met, life support is withdrawn, and organs are harvested Management of donor patients include? -Correct Answer= *Maintain BP *Monitor glucose, temperature, ABGs, fluids, & electrolytes *Treat anemia, coagulopathy, & thrombocytopenia *Provide appropriate mechanical ventilation (based on acid-base balance) Discuss catecholamine issues with organ donation -Correct Answer= Initial catecholamine release is followed by depletion resulting in vasodilation causing distributive shock. *Increase support when catecholamines decreased *Optimize Oxygenation What are neurohormonal regulations? -Correct Answer= *Thyroid hormones lead to cardiac issues 11 [Date] 2 *Pancreas hormones (insulin) lead to metabolic issue *Pituitary hormones lead to Diabetes Insipidus (increased UO) What are complications of organ transplant? -Correct Answer= *Rejection -Hyperacute = Immediate -Acute = Common, Can transfuse donor blood into recipient, symptoms mimic infection. *Infection -Anti-Rejection meds decrease immune Nurse -Prepare pt for biopsy -needs 1:1 care Nursing care for kidney transplant includes? -Correct Answer= Patient keeps old and new kidneys , takes 72 hours but goal is 12 hours. -Increased risk for trauma (wear mask) -Validate perfusion -Keep hydrated (increased risk for dehydration) -Evaluate all medical history -Prepare for dialysis prior -Closely eval kidney functions post surgery -No contact sports What medications are used for organ transplants? -Correct Answer= *Calcineurin inhibitor: Tacrolimus (Prograf)/Cyclosporine (Neoral) *Corticosteriod (Prednisone) *Mycophenolate Mofetil (CellCept) What are major complications of transplant medications? -Correct Answer= *Nephrotoxicity *Hypertension *Hyperlipidemia *Diabetes *Infection ~ Patient must be treated for any of these complications, they cannot stop transplant medications. 12 [Date] 2 What is considered a trauma? -Correct Answer= *Injury or wound caused by an external force or violence *Minor trauma: single system that does not pose a threat to life/limb *Major trauma: serious multiple system injuries that does pose threat to life/limb What is the mechanism of a blunt injury? -Correct Answer= *MVA *Motorcycle accident *Sports injury *Liver injury (most common) What is the mechanism of penetrating injury? -Correct Answer= *Knifes *Bullets *Debris *Liver most common organ injured What is the mechanism of blast injury? -Correct Answer= *Explosion (blast causes tissue/organ damage) *Usually involves blunt/penetrating trauma What is Primary Survey? -Correct Answer= *ABCDEFG - Done in 1-2 minutes A-Airway with cervical spine immobilization (Collar) B-Breathing & Ventilation C-Circulation with hemorrhage control D-Disabiilty or neurological status E-Exposure F-Full set of vital signs & family presence G-Get resuscitation adjuncts (Tests/support) What is secondary survey? -Correct Answer= *HI = Initiated after all actual/potential life-threatening injuries have been identified & addressed & resuscitation efforts initiated H-History and head-to-toe assessment I-Inspect posterior surfaces *Assessment = Inspection, palpation, percussion, & auscultation to identify injuries What are some complications associated with trauma? -Correct Answer= *Distributive shock - massive vasodilation *Head injuries 15 [Date] 2 *Caused by burns greater than 10-20% total body surface area *Effects up to 50% of vascular volume leading to burn shock *Causes edema in burned and unburned areas *Maximum edema 24-48 hours post burn What is the bodies immunity response to burns? -Correct Answer= *Tissue damage activates inflammatory cascades *Over-stimulation of suppressor T cells *Decreased T cells, T killer cells, & leukocyte activity What is the skin's response to burns? -Correct Answer= *Loss of barrier *Decreased thermoregulation *Increased evaporative H2O loss *Decreased tissue perfusion with possible tissue necrosis What is pulmonary response to burns? -Correct Answer= *Direct injury causes release of vasoconstrictive substances leading to pulmonary hypertension -Increased O2 demand -Decreased lung compliance What is renal response to burns? -Correct Answer= *Decreased urine output & GFR *Monitor for myoglobin *Followed by diuresis as fluid shifts What is gastrointestinal response to burns? -Correct Answer= *Ischemia due to redistribution of blood to brain & heart *Curling ulcers *Paralytic ileus What is metabolic response to burns? -Correct Answer= *Metabolic rates are 100%200% above basal rates *Decreased catecholamine release causing increased corticosteriod levels leading to hyperglycemia *Lasts up to 9-12 months after burn Describe hypovolemic shock from burns -Correct Answer= Massive loss of intravascular fluid due to increased vessel membrane permeability & evaporative losses through open wounds Describe distributive shock from burns -Correct Answer= *Third-spacing 16 [Date] 2 *Dramatic shifts in intravascular fluids *Mediator activation *Hyper exaggerated inflammatory cascade reaction Discuss emergent phase of burns -Correct Answer= *Resuscitative phase *Begins with injury *Priorities; -Airway -Circulation -Organ perfusion -Pain -Preventing infection -Body temp. -Emotional support Discuss acute phase of burns -Correct Answer= *Wound healing *Begins 36-72 hours *Ends with wound closure *Priorities; -Assess & Maintain cardio, renal, & GI systems -Nutrition -Wound care -Pain control -Psychosocial interventions Discuss rehabilitative phase of burns -Correct Answer= *Restorative *Begins when most of burn is healed *Ends when achieves highest level of function possible *Priorities; -Psychosocial support -Prevention of scares -Contractors What is prehospital care for small thermal burns? -Correct Answer= Cover with clean, cool, tap water (dampened towel) 17 [Date] 2 What is prehospital care for large thermal burns? -Correct Answer= Circulation,airway,breathing -Do not cool burns longer than 10 minutes -Do not immerse in cool water or pack with ice -Remove burned clothes -Wrap in clean, dry sheet or blanket What is prehospital care for inhalation burns? -Correct Answer= *Watch for signs of respiratory distress *Treat quickly & efficiently *100% humidified O2 if carbon poisoning Discuss fluid replacement for burn patients -Correct Answer= Directly replaces plasma fluid losses, fills newly increased body fluid reservoir, & restores preload deficits. How is fluid replacement for burns determined? -Correct Answer= *2 large bore IVs central line for severe burns *No normal saline (to high Na+ & Cl = hyperchloremic acidosis) Explain the Parkland formula -Correct Answer= -4mL/kg per % of TBSA burned -Gives the amount of LR to be infused over 24 hours -First half given over 8 hours -Second half given over next 16 hours What does the nursing care plan for burns include? -Correct Answer= 1.Pain management- Opiods, Ketamine 2.Infection prevention: no flowers, limit visitors, no fresh fruits/veggies, strict asepsis, wound care, vaccination. 3.Nutritional support: hypermetabolic & hypercatabolic state (5000kcal, High protein) 4.Restore mobility: body alignment, prevent contracture 5.Psychological support What is open method burn wound care? -Correct Answer= -used for facial burns -Topical antimicrobial ointments only What is closed method wound care? -Correct Answer= -Sterile gauze dressing impregnated with or laid over a topical antimicrobial -Change q12 hours - 14 days What are commonly used ointments/creams for burns? -Correct Answer= -Silver sulfadiazine (silvadene) 20 [Date] 2 *Medications What is DKA? -Correct Answer= Diabetic Ketoacidosis-severe metabolic derangement, altered mental status, coma & death. -Decreased insulin concentration. -Increased concentration of counter regulatory hormones (catecholamines, cortisol, glucagon, growth hormone) What are hallmark signs of DKA? -Correct Answer= *Metabolic acidosis *Hyperglycemia *Elevated levels of ketones in blood and urine *Dehydration What are causes of DKA? -Correct Answer= *Infection *Discontinuation/inadeq insulin therapy *Pancreatitis *MI *CVA *Medications (Corticosteriods, thiazide, sympathomimetic agents, anti-psychotic agents) What are clinical presentations of DKA? -Correct Answer= *Ketones *Hypotension *Polyuria *Polydipsia *Polyphagia *N/V *Drowsiness *Coma *Blurred vision *Emotional changes *Abdominal pain *Fruity scented breath *Tachycardia 21 [Date] 2 *Dehydration *Altered Mental Status What are the electrolyte goals for DKA patients? -Correct Answer= *Potassium = 45.5 *Magnesium = >2 *Phosphorus = >1 *Bicarbonate = >18 *Glucose = 150-200 What is HHS? -Correct Answer= hyperglycemic hyperosmolar syndrome -Associated with DM2 -Usually found in elderly -BS >600 (usually over 1000) -Has an higher mortality rate than DKA -Residual insulin secretion prevents ketosis What are symptoms of HHS? -Correct Answer= *Delirium *Polyuria *Polydipsia *wgt loss *Coma *Polyphagia *Aphasia *Seizures *Weakness *Dehydration *Hypokalemia *Sensory deficits *Somnolence *Focal/general seizures *Visual changes *Impaired sensation/function What is DI? -Correct Answer= Diabetes Insipidus *A water metabolism problem caused by 22 [Date] 2 -Antidiuretic hormone deficiency -Distal kidney tubules & collecting ducts not absorbing water *May be transient or chronic What are symptoms of DI? -Correct Answer= *Dehydration (causing most sxs) *Increased urine frequency (>4-20L) *Excessive thirst *Diluted urine (SG < 1.005) *Increased serum osmoloty *Decreased urine osmoloty *Increased sodium level What tests are used to diagnose DI? -Correct Answer= Dehydration & hypertonic saline tests What is the treatment for DI? -Correct Answer= *Low sodium diet *Fluids (D5W, 1/2 NS, 1/4 NS) *Hormone replacement -DDAVP = Desmopressin What are the 3 types of DI? -Correct Answer= *Central (Neurogenic) *Nephrogenic *Primary Describe primary DI -Correct Answer= Excessive water intake-psychological disorder or lesion in thirst center. Describe nephrogenic DI -Correct Answer= inadequate renal response despite the presence Describe central DI -Correct Answer= Central (Neurogenic): brain tumor, head injury, brain surgery, CNS infection What are interventions for DI? -Correct Answer= *Fluids: oral/IV -Acute DI: IV hypotonic saline/D5W -Titrate to replace UO *Monitor BS, BP, HR, UO, LOC, specific gravity What are interventions for Central DI? -Correct Answer= Hormone Therapy -DDAVP (Admin orally, IV, SubQ, or nasal) 25 [Date] 2 *Cerebral edema What is included in the admission assessment for TBI? -Correct Answer= *History -Mechanism of injury -Location & position -Immobilization -PMH *Psychosocial -Ongoing *Physical -VS -Head to toe -Disabilities What does the hourly assessments include? -Correct Answer= *Mental Status -GCS, expressive language, ability to follow commands *Focal Motor -Motor response (extremity movement) *Pupils -Size, shape, reaction to light *Brain stem/cranial nerves -Cranial nerves & assessment *Nuchal rigidity What is the hallmark sign in head injury for the need of a scan for bleeding? -Correct Answer= Pupil change What labs and diagnostics are needed for head injuries? -Correct Answer= *Labs -ABGs -CBC -Electrolytes *CT or MRI What are complications of TBIs? -Correct Answer= *Increased Intracranial Pressure (ICP) 26 [Date] 2 *Decreased Cerebral Perfusion Pressure (CPP) *DI *SIADH *Neurogenic Shock What is normal ICP? -Correct Answer= 5-15 mmHg What is high ICP? -Correct Answer= Sustained pressure >20 mm Hg What are interventions for increased ICP? -Correct Answer= 1. EVD 2. Hypertonic solution 3. Mannitol What does Mannitol do for increased ICP? -Correct Answer= Osmotic Diuretic, decreases MAP without decreasing volume. What does hypertonic solution do? -Correct Answer= increases MAP and pulls fluid to vascular system. -NS = 3%, 5%, 7% intermittent through out day -125mL with Sodium goal of 145 What is EVD? -Correct Answer= drain to decrease ICP What is MAP? -Correct Answer= the force that pushes blood into the brain -Normotensive person = 70-150 What does the cranial vault consist of? -Correct Answer= *Brain tissue = 80% *Blood = 10% *CSF = 10% What causes increased ICP? -Correct Answer= *Increased brain volume *Increased cerebral blood volume *Factors increasing O2 demand *Factors decreasing venous return *Increased cerebrospinal fluid What increases cerebrospinal fluid? -Correct Answer= CSF flow or absorption block What is a factor that decreases venous return? -Correct Answer= cough 27 [Date] 2 What are factors that increase oxygen demand? -Correct Answer= *Fever *Seizures What increases cerebral blood volume? -Correct Answer= *Vasodilation (more Volume) *Hypercapnia (increased CO2) *Acidosis (lactic acid) *Hypoxemia What causes increased brain volume? -Correct Answer= Cellular edema Ways to decrease metabolic demand? -Correct Answer= *Anticonvulsants *Temperature control *Sedation/Pain *Quite calm environment What are the 3 types of intracranial hemorrhage? -Correct Answer= 1. Epidural -Usually arterial -Surgical emergency 2. Subdural -Usually venous -3 types -Elderly high risk r/t falls 3. Intracerebral -Bleeding into the brain tissue -Usually frontal/temporal lobes What are causes of hemorrhagic stroke? -Correct Answer= *Ruptured aneurysm *Ruptured arteriovenous malformation *Severe HTN *Cocaine & amphetamine abuse *Falls What are assessment findings of hemorrhagic stroke? -Correct Answer= *Sudden onset *Worse HA ever *Increased ICP 30 [Date] 2 *Spinal anesthesia *Elevated HOB- prevents progressive spinal blockage *Spinal stability How can hypotension be treated during neurogenic shock? -Correct Answer= *Cautiously admin fluids up to 2L *Vasopressors (dopamine/norepi) How is bradycardia treated? -Correct Answer= *Pacemaker *Atropine What are interventions for spinal cord injury? -Correct Answer= Immobilization/surgery -Traction -Halo -TLSO What are complications of spinal cord injury? -Correct Answer= -Atelectasis -Pneumonia -Respiratory failure -Sleep apnea syndrome -Orthostatic hypotension -Increased risk for DVT -Autonomic dysreflexia -Spasticity -Decreased lean muscle mass -Osteoporosis -Neurogenic bladder -Neurogenic bowel -Nociceptive pain -Neuropathic pain What medications are used for spasticity? -Correct Answer= *Baclofen *Botox *Benzodiazepines 31 [Date] 2 What medication is used for osteoporosis? -Correct Answer= Bisphosphonates What are common problems from neurogenic bladder? -Correct Answer= *Urgency *Frequency *Incontinence *Inability to void *High bladder pressure What is the treatment for neurogenic bladder? -Correct Answer= Clean intermittent catheterization What are common problems of neurogenic bowel? -Correct Answer= *Constipation *Incontinence *Hemorrhoids *Impaction What are treatments for neurogenic bowel? -Correct Answer= *High fiber diet *Metamucil/stool softeners/oral laxatives *Gastrocolic reflex *Manual evacuation *Digital rectal stimulation *Rectal suppository *Abdominal massage *Sacral nerve stimulation *Colostomy What are symptoms of autonomic dysreflexia? -Correct Answer= *Severe hypertension *Bradycardia *Severe HA & blurred vision *Flushing above/pale below lesion *Sweating *Nausea *Anxiety Discuss nociceptive pain -Correct Answer= *Abnormal posture, gait, overuse *Muscle spasm Discuss neuropathic pain -Correct Answer= *Above lesion: arise from complex regional pain syndrome 32 [Date] 2 *At lesion: Damage to nerve roots or spinal cord itself *Below lesion: Central dysesthesia syndrome -Burning -Aching -Tingling -Stabbing sensation What pain treatment is used for pain from SCI? -Correct Answer= *Opiods *Anticonvulsants *Antidepressants *Antispasmodic *Acupuncture *Spinal cord stimulation *Transcutaneous electrical nerve stimulation What are interventions for autonomic dysreflexia? -Correct Answer= *Induce hypoorthostat by placing patient in sitting position. *Assess & alleviate cause *Treat symptoms (Nifedipine & Nitrates) *Monitor vitals Q 5 minutes *Educate on recognition & report of symptoms What are interventions for spinal cord injuries? -Correct Answer= *Promote independence -ADLs -Mobility -Bowel/Bladder care -Sexuality *Collaborative care -Rehab -Home care -Mental health What's the nursing role for GI bleeds, Cirrhosis, and pancreatitis? -Correct Answer= *Assessment *Past medical history