Exam Questions and Answers for NUR 2755 Multidimensional Care IV: Neurological Emergencies, Exams of Nursing

Download Exam Questions and Answers for NUR 2755 Multidimensional Care IV: Neurological Emergencies and more Exams Nursing in PDF only on Docsity! NUR 2755 Multidimensional Care IV / MDC 4 Exam Questions and Answers Latest Updates 2024 • muscle weakness increase uncordination confusion apathy incoherence decreased clotting Pneumothorax interventions MS physical assessment Frsotbite physical assessment Moderate hypothermia symptoms • 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) • worst headache ever subarachnoid hemorrhage symptom Spinal Cord Injury Intervention Right hemisphere stroke changes Guillian Barre Syndrome patho • infectio n vaccine autoimm une ARF ABG's 1 of 45 4/6/2021, 10:31 • complete- no function below injury incomplete- some function below injury Spinal cord injury complete vs incomplete Spinal Cord Injury Intervention 3 of 45 4/6/2021, 10:31 Triage rules HEat stroke prehospital interventions • Tonic- clonic tonic clonic myoclo nic atonic Multiple sclerosis patho Generalized Seizures types Seizure Diagnostic testing Severe hypothermia symptoms • could wait several hours and survive ex. rash strains and sprains colds simple fractures Non urgent triage ARF interventions Myasthenic crisis Vent care • 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 autonomic dyreflexia Autonomic Dysreflexia causes • 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 • dyspne a low O2 irritabl e confus ed tachyca rdia decrease d loc headach e drowsy GBS physcial assessment ARDS physical assessment Glascow coma scale scores Mass causualty triage tags 6 of 45 4/6/2021, 10:31 • ulcers-PPI-dine H2 blocker prazole enteral feeding electrolyte replace Heat exhaustion interventions Frsotbite physical assessment Mass causualty triage tags Vent complications and prevention • sudden dyspnea sharp stabbing chest pain anxiety cough tychyp nea crackl es pleural friction rub s3 or s4 sounds diaphoresis fever decreased SaO2 Pneumothorax interventions Plasmaphersis watch out for ARDS Physcial Assessment P.E. physical assessment Cushing triad ARF ABG's • distorted acetylcholine receptors 8 of 45 4/6/2021, 10:31 hyperplasia of thymus gland ARDS Phases GBS causes MG causes P.E. Surgery • tumor or trauma metabolic disroders acute alchohol withdrawl electrolyte imbalance fever stro ke TBI substan ces heart disease Causes fo seizures secondary Stroke emerency interventions Severe hypothermia symptoms Causes of seizures Primary • idiopathic genetic factors Generalized Seizures types Causes of seizures Primary partial seizure types Left hemisphere stroke changes Parkinson's surgical treatment • myalgia headaches anaphylaxis asepetic meningitis IVIG complications Left hemisphere stroke changes GBS lab diagnosis Heat exhaustion symptoms • 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 • decide who get a room when highest acuity gets a room first MG causes Spinal cord injury complete vs incomplete Triage rules Vent bundle • 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 • age gend er histo ry race- native, black, latino Myasthenia Gravis patho • 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 • fatigue stress overexer tion temperat ures Seizure Phases MS aggravators MG lab diagosis MS Lab diagnostics • 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 • 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 chest pain with sweating stroke active hemmorhage unstable vital signs Triage Emergent Triage Urgent Spinal cord injury complete vs incomplete ARDS Interventions • 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 • B- balanc e E- Eyes F- face A- arms S- speec h T- time Stroke Risk factors non modifiable Heat exhaustion symptoms Seizure Diagnostic testing Stroke Initial assessment • 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 • muscles suddenly become limp. Part or all of the body may become limp Autonomic Dysreflexia causes 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 • 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 • too much meds Anaphylaxis bee treatment Non urgent triage Vent bundle P.E. Surgery • 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 • 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 • 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 • HTN Diabetes hyperlipid emia 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 • cool patietn down remove clothing cold water on body fan ice packs = ARDS Causes • oxygen doesn't get into lungs, airway issue ARF interventions ARDS Causes = Shock treatment ARF vent • respiratory assessment suctioning physiotherapy activity after meds protect eyes Heat exhaustion interventions ARDS physical assessment Stroke emerency interventions MG non-surgical interventions • temporary stroke that leaves no mark behind TIA patho MS Drugs Types of MG Spinal shock • parethsesi = as muscle weakness loss of reflexes in arms/legs low BP/ poor BP control muscle weakness without muscle atrophy uncoordinated movements blurred vision palpatio ns decreased respiratory function = upright position energy- conservation parkland formula GBS interventions ARF interventions ARDS Interventions • 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 • flu-like headache heavy sweating Anaphylaxis bee treatment = Heat exhaustion symptoms Seizure Diagnostic testing ARDS Physcial Assessment • 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 • 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 ARDS Physcial Assessment ARF oxygenation GBS physcial assessment • 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 tonic-clonic seizure (grand mal) Spinal cord injury physical assessment Frostbite interventions • vasoconsrictors dopamine, nor epi Inotropic agents (increase heart contraction)- dobutamine, milirone Myocardial perfusion enhancers- nitroprussides Cushing triad TIA symptoms MS Drugs Shock drugs • no pull at tube monitor vitals, respiratory status, ABG's HOB above 30 degrees check vent settings regularly Mouth care q 2 monitor for weaning Tonic Seizure Vent bundle Non urgent triage Vent care • arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward. The muscles are tightened and held rigidly. This type of posturing usually means there has been severe damage to the brain. Feeling lightheaded Difficulty sleeping Difficulty staying focused Behaviour changes. Heat stroke symptoms Seizure phase post ictal Seizure Phases seizure phase Prodomal • language deficits anxiety/depre ssion right sided weakness Guillian Barre Syndrome patho Right hemisphere stroke changes Left hemisphere stroke changes Vent complications and prevention • seizuer-sudden uncontrolled electrical discharge of neurons epilepsy-2 or more seizures Secondary survey Non urgent triage decoricate posture Seizures (Epilepsy) • 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 • 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 • autoimmune disease muscle weakness Seizure Diagnostic testing -Ice or cool water compress -Antihistamine (oral or topical) Frsotbite physical assessment Bee sting treatment decoricate posture Myasthenia Gravis patho • decreased reflexes, loss of sensation, and flaccid paralysis below the level of injury immediately with injury can be with neurogenic shock ARDS Physcial Assessment Secondary survey Increased ICP symproms Spinal shock • body tissue freezes, like a burn can be superficial partical or full thickness Frsotbite physical assessment HEat stroke prehospital interventions Frostbite interventions Bee sting treatment • reduced breath sounds on affected side prominence of involved side of chest deviated trachea if tension distended neck veins Severe hypothermia symptoms pneumothorax physical assessment Heat exhaustion interventions Heat stroke hospital interventions • choliesterase inhibitors- pyridostigmine immunosuppressant- methotrexate, rituximab, steroids IVIG for acute treatment MG drug intervention autonomic dyreflexia ARDS Interventions P.E. Intervention • sign of increased ICP -Widening of pulse pressure, -Slowing HR -severe HTN Vent bundle Cushing triad Bee sting treatment ARF oxygenation • 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 • 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 • 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 • airway management (especially above T-6) Vent PRN manage secretions decreased RR cardiac dysrythmias decreased neurologic reflexes decreased pain response acid-base imbalance Plasmaphersis watch out for Stroke Risk factors modifiable Severe hypothermia symptoms pneumothorax physical assessment • 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 • 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 • embolectomy-removal of embolist IVC filter- short term fix to block the embolist from reaching the lungs ARDS physical assessment MS physical assessment GBS physcial assessment P.E. physical assessment • temp over 104 emergen cy Cholinergic crisis HEat stroke prehospital interventions GBS interventions Heat stroke patho • determine surface area of body head=9 each arm=9 each leg=18 torso= 36 Seizure Phases MG causes neurogenic shock Rule of nine • PaO2 less than 60 SaO2 is less than 90 TIA patho ARDS Causes Vent bundle ARF ABG's • prodromal, aural, ictal, postictal Seizure phase post ictal Seizure Phases Simple seizure Seizure Diagnostic testing • demyelination and axonal nerve damage Multiple sclerosis patho partial seizure types Stroke Initial assessment Generalized Seizures types • end-tidal CO2 and x-ray • complex/autom atisms simple Causes of seizures Primary Generalized Seizures types partial seizure types MG surgical intervention • Plasmaph erisis IVIG GBS interventions GBS lab diagnosis MG drug intervention P.E. Intervention • monitor for hypocalemia uticaria coagulopa thy risk for infections fluid overload sensitivity Autonomic Dysreflexia causes Plasmaphersis watch out for ARDS Physcial Assessment Frsotbite physical assessment • 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