NUR 2755 Multidimensional Care IV / MDC 4 Exam 3 Review-with verified answers-2024-2025, Exams of Nursing

Download NUR 2755 Multidimensional Care IV / MDC 4 Exam 3 Review-with verified answers-2024-2025 and more Exams Nursing in PDF only on Docsity! NUR 2755 Multidimensional Care IV / MDC 4 Exam 3 Review-with verified answers- 2024-2025 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 1 of 45 4/6/2021, 10:31 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 4 of 45 4/6/2021, 10:31 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 5 of 45 4/6/2021, 10:31 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. dys pnea low O2 irritable confused tachycardi a decreased loc headache drowsy GBS physcial assessment ARDS physical assessment Glascow coma scale scores Mass causualty triage tags 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. Preve ntative: Avonex Betaseron Copaxon Acute-steroids and baclofen Shock drugs MS Drugs Cushing triad ARF ABG's 22.distorted acetylcholine receptors 8 of 45 4/6/2021, 10:31 9 of 45 4/6/2021, 10:31 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 12 of 4/6/2021, 10:31 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 13 of 4/6/2021, 10:31 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 14 of 4/6/2021, 10:31 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 185/110 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 17 of 4/6/2021, 10:31 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 18 of 4/6/2021, 10:31 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 O2 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 19 of 4/6/2021, 10:31 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 22 of 4/6/2021, 10:31 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. 23 of 4/6/2021, 10:31 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 24 of 4/6/2021, 10:31 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 27 of 4/6/2021, 10:31 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 28 of 4/6/2021, 10:31 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 29 of 4/6/2021, 10:31 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 32 of 4/6/2021, 10:31 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 33 of 4/6/2021, 10:31 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) 34 of 4/6/2021, 10:31 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 37 of 4/6/2021, 10:31 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 38 of 4/6/2021, 10:31 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 39 of 4/6/2021, 10:31 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 42 of 4/6/2021, 10:31 Stroke Risk factors modifiable Severe hypothermia symptoms pneumothorax physical assessment 105. Minor 12-15 Moderate 9-12 severe-3-8 below 8 prepare to intibate Glascow coma scale scores Causes of seizures Primary HEat stroke prehospital interventions ARDS physical assessment 106. repeated jerking movements of the arms and legs on one or both sides of the body, sometimes with numbness or tingling. If it is a focal (partial) seizure, the person may be aware of what's happening. During a generalized seizure, the person may be unconsciou Flail chest Clonic seizures TIA symptoms Simple seizure 107. embolectomy-removal of embolist IVC filter- short term fix to block the embolist from reaching the lungs 43 of 4/6/2021, 10:31 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 44 of 4/6/2021, 10:31 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 partial seizure types MG surgical intervention 119. Plasmap herisis IVIG GBS interventions GBS lab diagnosis MG drug intervention P.E. Intervention 120. monitor for hypocalemia uticaria coagulopathy risk for infections fluid overload sensitivity Autonomic Dysreflexia causes Plasmaphersis watch out for ARDS Physcial Assessment Frsotbite physical assessment 121. CSF-elevated protein, myelin basic protein IgG bands MRI-brain or spinal cord plaques Bee sting treatment Frsotbite physical assessment 44 of 45 4/6/2021, 10:31 MS Lab diagnostics MG drug intervention