Nursing 302 Exam 4 Questions With Complete Solutions, Exams of Nursing

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Nursing 302 Exam 4 Questions With Complete Solutions C1-C7 injury - Correct answer affects respirations, heart, breathing and everything below it T1-T2 injury - Correct answer affects abdominal muscles, bowel, bladder, legs, and sometimes the arms S1-S4 injury - Correct answer bladder control, uterus, and penia coccyx injury - Correct answer unable to sense when bladder or bowel are full spinal chock manifestations - Correct answer low bp, decreased reflexes, bradycardia, warm skin above injury causes of spinal shock - Correct answer lots of communication above injury but not below it can be due to distended bowel, or bladder, or infection ways to to treat spinal shock - Correct answer atropine for HAR, steroids, IV fluids to increase BP neurogenic dysreflexia (hyperreflexia) manifestations - Correct answer seizure, high BP, bradycardia, bad headache, sweating, facial flushing causes of neurogenic dysreflexia - Correct answer misscomunnication bc body is sensing something is wrong below injury but does not know what ways to treat hyperreflexia - Correct answer raise HOB to 45-90 degrees, remove stimuli, call HCP, look for culprit incomplete injury - Correct answer some sensory and stimulation is felt complete injury - Correct answer no message, cord is severed does a spinal cord bruise every go away - Correct answer no it never goes away, pt may get dysthesia neurogenic shock - Correct answer low BO, low HR loss of vascular tone and tight, becomes floppy which slows O2 delivery to heart three cares for Sarah's Gardner-Wells tong's and traction - Correct answer frequent skin assessment around tons pin cares per hospital protocol ensure weights are hanging freely baclofen & sci - Correct answer muscle relaxant used to decrease muscle spasms; some patients have pump for it bisacodyl & SCI - Correct answer laxative used for easy passage of stool oxybutnin - Correct answer anticholinergic used for bladder spasms enoxaparin - Correct answer anticoagulant used to prevent DVT immediate intervention for autonomic dysreflexia - Correct answer elevate HOB, put feet down, and remove restrictive clothing order of what to do if pt is experiencing autonomic dysreflexia - Correct answer 1) elevate HOB 2) lower feet 3) remove restrictive clothing 4) retake BP after 2-3 minutes in the position 5) call HCP to inform them of event 6) Administer a prn prescribed sublingual nifedipine for continued elevated BP 7) remove impacted stool or urine etc baclofen withdrawal - Correct answer extreme muscle spascity, seizure, agitation, pain quad coughing technique - Correct answer -elevate HOB to high fowlers position -put hands on upper abdomen, client inhale, push upward with client cough most appropriate for the nurse to plan to instruct on the use of intermittent self-urinary catheterization - Correct answer pt with SCI and no awareness of when to void The adolescent who had a T10 complete SCI reports leaking of urine at fairly regular intervals. The nurse should plan interventions for which type of incontinence? - Correct answer reflex Poikilothermism - Correct answer ability to maintain normal body temperature symptom of neurogenic shock neurogenic vs spinal shock - Correct answer spinal shock is due to an acute spinal cord injury and is abscence voluntary and reflexive activity below level of injury neurogenic shock --> hemodynamic phenomenon resulting in loss of vasomotor tone and occurs within 30 minutes for cord injuries above T5, can last up to 6 weeks uthoff's symptoms - Correct answer heat sensitivity in MS that causes nerve endings to conduct more (usually affects vision) major liver functions - Correct answer processing and breaking down fats, CHO, and protein creates elements needed for bodily function eliminate waste and toxic substances what does the liver produce - Correct answer albumin, clotting factors, cholesterol, bile affect cirrhosis has on rbc and wbc - Correct answer blocked blood flow to liver --> back up in portal vein --> spleen becomes backed up and enlarged --> destroys blood components at an accelerated rate fatigue & cirrhosis - Correct answer spleen breaks down blood (RBC) liver cannot breakdown fats, glucose, and protein as fast as it used to RUQ pain & cirrhosis - Correct answer obstruction of blood in liver --> liver capsule stretches and vascular & biliary ducts can spasm treatment for early cirrhosis - Correct answer diet (low fat, high CHO), milk thistle, medical marijuana, megestrol acetate, fat soluble vitamins (A & K), b vitamins itching & cirrhosis - Correct answer bile salts get under skin signs of worsening cirrhosis - Correct answer bleeding, worsened labs, wt loss, steatorrhea, gynecomastia, spider angianomas, skin itching three causes of ascites - Correct answer too much aldosterone, low albumin, protein rich lymph fluid & plasma leaks out of liver sinusoids into peritoneal space complication of ascites - Correct answer spontaneous bacterial peritonitis ascites treatment - Correct answer direutic (furosemide, spironolactone), TIPS, decreased sodium, pancreacentesis varices - Correct answer pressure in the portal system develops and collateral veins are developped to compensate but are not strong, risk of bleeding varices treatment - Correct answer prevent bleeding is the priority beta blocker to decrease vein pressure chewing food throughly and avoiding coarse foods octreotide (Sandostatin) IV fluids and blood products vitamin K endoscopic therapy balloon tamponade Hepatic encephalopathy - Correct answer caused by the liver's failure to eliminate and detoxify toxins (usually ammonia) what do the toxins then cause - Correct answer altered neurotransmission and CNS toxicity signs of HSE - Correct answer irritation, confusion, asterexisis, fine hand tremors, sweet foul smelling breath, HSE treatment - Correct answer decreased protein intake, lactulose, K+ replacement, antibiotics risk factors for gallbladder disease - Correct answer Multiparous, hormones, obesity, rapid weight loss, female, over 40, Caucasian, obesity, fam hx, native American, very low fat diets, prolonged fasting or parenteral nutrition what is important to check with TPN - Correct answer blood glucose lifestyle habits to assess with chronic pancreatitis - Correct answer Chronic alcoholism is one of the most common causes of chronic pancreatitis Causes inflammation and tissue is unable to repair itself and becomes fibrotic Smoking is also a risk factor Smoking + alcohol = big risk factor ulcerative colitis vs crohns - Correct answer UC only affects inner layer of colon crohns affects all layers of small intestine where much of the nutrients are absorbed risk factors for acute pancreatitis - Correct answer Gallstones 70 years old Drinking/alcohol use biliary colic - Correct answer Used to describe a type of pain related to the gallbladder that occurs when a gallstone transiently obstructs the cystic duct and the gallbladder contracts labs to observe with acute pancreatitis - Correct answer Lipase and amylase two complications of ulcerative colitis - Correct answer anemia dehydration symptoms of chronic pancreatitis - Correct answer Pain, diarrhea, nausea, vomiting, jaundice, constipation, fatty/oily stool, malabsoprtion of food, diabetes symptoms of hypocalcemia - Correct answer tetany muscle twitching Chvostek à touch face and there is lil twitch Tristeau: dorsal flexion of rest with decreaed blood flow Vocal cord spasms: laryngeal stridor Throat: dysphagia Seizures why does low calcium and pancreatitis go together - Correct answer Lipase is actived in pancreas à fatty tissue of the pancreas is broken down, fatty acids are released, calcium combines with fatty acids, serum calcium levels decrease lipase is high with pancreatitis so more calcium is broken down pseudocyst - Correct answer local complication of acute pancreatitis collection of pancreatic enzymes and plasma fluids enclosed in a wall of fibrous or granulation tissue Usually occurs after an attack of acute pancreatitis concerns with pseudocyst - Correct answer infection, rupture, press on adjacent body structures (intestine, common bile duct) Cholestyramine - Correct answer used for diarrhea/dehydration treats bile acid diarrhea 5-HT3 receptor antagonists crohns COBALAMIN - Correct answer Vitamin B12 treats malnutrition and anemia w/crohns major complication of ulcerative colitis - Correct answer toxic megacolon systemic pulmonary issue with pancreatitis - Correct answer bleeding into peritoneal space Circulating blood volume is decreasing Enzymes creep up into lung tissue and irritate lungs (can actually develop acute repisratory distress syndrome) toxic megacolon - Correct answer widening of large intestine fistula - Correct answer abnormal passageway between two organs or between an internal organ and the body surface crohns fistula treatment - Correct answer Bowel rest, may have tPN, IV fluids, NPO small bowel resection cure for UC - Correct answer colon removal diet for IBD exacerbation - Correct answer NPO, TPN