Nr 325 Exam 2-With 100% Verified Questions And Answers | Graded A+, Exams of Nursing

Download Nr 325 Exam 2-With 100% Verified Questions And Answers | Graded A+ and more Exams Nursing in PDF only on Docsity! Nr 325 Exam 2-With 100% Verified Questions And Answers | Graded A+ what are s/s of head injury? leakage of CSF Ecchymosis Battle's sign/raccoon eyes what is management of head injury? ensure patient airway* priority what is the Monro-Kellie doctrine? If one component increases, another must decrease to maintain ICP. only applicable to closed skull patients* what is normal ICP level? 5-15mmHg >20mmHg needs treatment!! What are key features of increased ICP? CUSHINGS TRIAD lethargy to coma change in speech cranial nerve dysfunction seizures abnormal posturing what is cushings triad? elevated BP, Decreased pulse, and decreased respirations. KEY characteristic of increased ICP how do we manage patients leaking CSF? raise head of be NO sneezing/blowing nose/bleeding NO NG tube, nasotracheal suctioning How do we place a patient with increased ICP? elevated HOB atleast 30 degrees what is the treatment for increased ICP? maintain AIRWAY* Hyperventilate patient to "blow off" CO2 (CO2 dilates blood vessels) Raise HO Decrease metabolic demands by paralyzing and sedating patient Mannitol- only diuretic given for ICP corticosteroids Pain management Intracranial monitoring (in ventricle) Craniotomies- removes portion of skull to allow for brain to swell. Decompressive craniectomy what is the ONLY diuretic given for increased ICP? Mannitol what are risk factors of stroke? Obesity Heart disease 2. 3. 4. maintain patent airway protect pt's head, turn patient to side, ease to floor if sitting do not restrain the pt do not place any objects in the patients mouth what are the signs and symptoms of meningitis? SEVERE headache fever nausea/vomiting nuchal rigidity photophobia decreased LOC - caused by increased ICP what is the CSF finding for bacterial meningitis? cloudy increased WBC, PROTEIN, decreased glucose elevated CSF pressure >180mmHg H2o how do we treat bacterial meningitis? AGGRESSIVE antibiotics (ampicillin, penicillin, vancomycin,etc) REST IV FLUIDS codeine for headache corticosteroids- inflammation anticonvulsants- precaution seizure closing the blinds, keeping room dark (photophobia) how do we test for bacterial meningitis? Lumbar puncture test blood culture ct scan how do we test for viral meningitis? Lumbar puncture test Xpert EV test what are the CSF findings of viral meningitis? clear increased WBC SLIGHTLY elevated protein normal glucose* variable CSF pressure what are the S/S of parkinson's disease? think TRAP* Tremor Rigidity Akinesia Postural instability slow movement gait disturbance tremor at rest rigid muscle tone how do we manage parkinson's? symptom management drug thereapy- antiparkinsonian drugs levodopa (sinemet) is the primary tx for symptoms nutritional therapy- adequate fiber and fruit, soft easy to swallow foods what is myasthenia gravis? autoimmune disease causing fluctuating weakness of skeletal muscle s/s of myasthenia gravis? muscles stronger in the AM and WEAKER at the end of day. facial mobility & expression impaired MASK LIKE EFFECT* difficulty breathing, weak hoarse voice, neck, shoulder and hip affected what is a MAJOR complication of myasthenia gravis? myasthenic crisis- an acute exaberation of muscle weakness trigggered by resp. infection, surgery, etc CAUSING dysphagia and difficulting breathing. (aspiration and resp. infection) what is the priority for myasthenia gravis? airway, aspiration prevention What is the tensilon test? this test reveals improved muscle contractility after IV injection of Tensilon (anticholinesterase agent) this test also aids in diagnosis of cholinergic crisis which occurs due to excessive cholinesterase inhibition management of myasthenia gravis? drug therapy- anticholinesterase drugs, corticosteroids, immunosuppressants. surgical therapy- removal of thymus gland plasmapheresis - removes antibodies IV immunoglobulin G - reduces antibody production destruction of myelin sheath of neurons what are s/s of MS? first presenting symptoms : Changes in sensation* Incoordination, loss of balance* Visual problems (diplopia-double vision)* later symptoms: Muscle weakness Dysarthria Dysphagia Fatigue Bladder and bowel problems Cognitive impairment Heat intolerance treatment of MS includes ? drug therapy to minimize symptoms - immunomodulator drugs copaxone (decreases inflammation) avonex (interferon Beta) crede procedure- massaging pelvic area to stimulate patient to urinate what is the priority care for MS? airway/breathing a spinal cord injury about C4= paralysis of resp. muscles and all four extremities. Spinal cord injury from C1-C3= often fatal movement in neck and above loss of independent resp function SCI C5= full neck, partial shoulder, back and bicep movement inability to roll over or use hands decreased resp. reserve SCI C6= partial paralysis of hands and arms as well as lower body decreased resp. reserve SCI C7-C8 can move triceps to elbow extension, finger extensors and flexors good grasp w some decreased strength decreased resp. reserve SCI T1-6 = movement of upper extremities full strength grasp in hand decreased trunk stability & decreased resp. reserve SCI T6 paraplegia below chest SCI L1= paraplegia below the waist T12= bowl is flaccid complications of spinal cord injury? and how do we manage them? airway first- ventilator if needed, prevent complications of immobility- skinbreakdown , DVT, atelectasis bladder retraining (spastic or flaccid)- foley catheter, suppository, etc who will be providing care for a spinal cord injury? OT PT speech therapy s/s of autonomic dysreflexia? sudden and severe throbbing headache severe hypertension bradycardia how do we care for autonomic dysreflexia? place pt in sitting position check foley cath for kink check bladder for distention check for bowel impaction this stroke is caused by a blockage of a blood vessel. (atherosclerosis) ischemic stroke this stroke occurs from a formation of a blood clot causing a narrowing of the lumen thrombotic stroke