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113 Cards in this Set
- Front
- Back
Patient has dilated Pupil, what cranial nerve?
What do the 2nd, 3rd, 4th, and 7th cranial nerves do? |
Patient has dilated Pupil, what cranial nerve?
-Cranial Nerve III What do the 2nd, 3rd, 4th, and 7th cranial nerves do? Cranial Nerve II, Optic – Sensory nerve (retina) responsible for central and peripheral vision. Cranial Nerve III, Oculomotor – Motor responsible for eye movement, lid elevation, pupil constriction. Cranial Nerve IV, Trochlear – Motor nerve responsible for turning eye down and inward. Cranial Nerve VII, Facial – Motor and sensory nerve responsible for movement of the face and scalp and pain, lacrimation (tear formation) and salivation, and temperature of the ear area, deep sensations from the face, and taste from the anterior 2/3 of the tongue. |
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Extraoccular movement, what cranial nerves should be tested?
What do the 2nd, 3rd, 4th, 5th, and 6th cranial nerves do? |
Extraoccular movement, what cranial nerves should be tested?
-Cranial Nerves 3, 4, and 6 What do the 2nd, 3rd, 4th, 5th, and 6th cranial nerves do? Cranial Nerve II, Optic – Sensory nerve (retina) responsible for central and peripheral vision. Cranial Nerve III, Oculomotor – Motor responsible for eye movement, lid elevation, pupil constriction. Cranial Nerve IV, Trochlear – Motor nerve responsible for turning eye down and inward. Cranial Nerve V, Trigeminal – Motor and sensory nerve responsible for chewing; face, scalp, and oral mucosa sensation; corneal reflex. Cranial Nerve VI, Abducens – Motor nerve responsible for lateral (outward) eye movement. |
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Patient with mouth drooping on the side, which cranial nerve is affected?
What do the 6th, 5th, 7th, and 10th cranial nerves do? |
Patient with mouth drooping on the side, which cranial nerve is affected?
-Facial or 7th cranial nerve What do the 6th, 5th, 7th, and 10th cranial nerves do? Cranial Nerve VI, Abducens – Motor nerve responsible for lateral (outward) eye movement. Cranial Nerve V, Trigeminal – Motor and sensory nerve responsible for chewing; face, scalp, and oral mucosa sensation; corneal reflex. Cranial Nerve VII, Facial – Motor and sensory nerve responsible for movement of the face and scalp and pain, lacrimation (tear formation) and salivation, and temperature of the ear area, deep sensations from the face, and taste from the anterior 2/3 of the tongue. Cranial Nerve X, Vagus – Motor and sensory nerve responsible for swallowing, speech, gag reflex and pain and temperature from ear, sensations of pharynx, larynx, soft palate. |
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When assessing the 10th cranial nerve (Vagus), what equipment do you need?
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When assessing the 10th cranial nerve (Vagus), what equipment do you need?
Tongue Blade |
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After a head injury, the patient is unresponsive to certain types of stimulation and the nurse understands that general sensations such as heat, cold, pain, and touch are registered in what lobe of the brain?
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After a head injury, the patient is unresponsive to certain types of stimulation and the nurse understands that general sensations such as heat, cold, pain, and touch are registered in what lobe of the brain?
Parietal Lobe – Primary sensory area – interpretation of touch, pain, and temperature. |
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What clinical indicators (symptoms) does the nurse expect to identify when assessing a patient with a brain injury in the occipital lobe.
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What clinical indicators (symptoms) does the nurse expect to identify when assessing a patient with a brain injury in the occipital lobe.
Visual problems Occipital Lobe – Visual receiving and visual association area. |
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Patient with expressive aphasia, what does this mean?
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Patient with expressive aphasia, what does this mean?
Trouble talking or speaking (using words and sentences) Broca's area (motor speech area) – control of speech muscles in tongue, soft palate, and larynx (problem: expressive aphasia) (in the Frontal Lobe) |
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A patient with sustained trauma to the Broca area (expressive aphasia) (Frontal lobe), how is the nurse going to compensate for these defects?
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A patient with sustained trauma to the Broca area (expressive aphasia) (Frontal lobe), how is the nurse going to compensate for these defects?
Use a white board, paper and pen, pointer board with special words. Broca's area (motor speech area) – control of speech muscles in tongue, soft palate, and larynx (problem: expressive aphasia) (in the Frontal Lobe) |
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A patient with a head injury is having problems with sensory function, the nurse understands what structure acts as a relay system (station) in the brain?
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A patient with a head injury is having problems with sensory function, the nurse understands what structure acts as a relay system (station) in the brain?
Thalamus – relay station for sensory impulses sorts out the impulses and directs them to other areas of the cerebral cortex. |
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Soon after admission with a head injury, a client's temperature rises to 102.8 F, which structure is injured?
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Soon after admission with a head injury, a client's temperature rises to 102.8 F, which structure is injured?
Hypothalamus – helps maintain homeostasis Body temperature, water balance, sleep, appetite, fear and pleasure Regulates SNS and PNS |
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What is the Glasgow Coma Scale?
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What is the Glasgow Coma Scale?
Rapid neurological assessment used when a client is admitted to a health care facility on an emergent basis Establishes baseline data in these areas: eye opening, motor response, and verbal response A score of 15 represents a normal neurological functioning A score of 7 represents a comatose state The lower the score, the lower the client's LOC |
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Glasgow Coma scale
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Glasgow Coma scale Score
Eye opening Spontaneously 4 To Speech 3 To Pain 2 None 1 Verbal Response Orientated 5 Confused 4 Inappropriate 3 Incomprehensible 2 None 1 Motor Response Obeys Commands 6 Locates to Pain 5 Withdraws from Pain 4 Flexion to Pain 3 Extension to pain 2 None 1 “If score is 8, you must intubate” - 5 Glasgow Coma Scale questions |
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What is Doll's eyes?
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What is Doll's eyes?
A Doll's eyes (dead or brain dead) will go with the head when the head is turned, but a human's eyes will stay in one spot when the head is turned if they are not dead. “The oculocephalic reflex, also known as the vestibulo-ocular reflex (VOR), oculovestibular reflex, or doll's eye reflex, is the movement of the eyes for maintaining forward gaze in response to rotation of the neck to a particular direction” In cases of accidents and brain injuries, a negative oculocephalic reflex (doll's eye reflex) is considered a very poor prognosis The test is also carried out to assess if a client is brain dead |
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A patient is found unconscious at home and brought to the hospital and has doll's eyes, what is the test you would do to demonstrate doll's eyes?
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A patient is found unconscious at home and brought to the hospital and has doll's eyes, what is the test you would do to demonstrate doll's eyes?
To evaluate the patient's oculocephalic reflex (doll's eye reflex), hold her upper eyelids open and quickly (but gently) turn her head from side to side, noting eye movements with each head turn. With absent doll's eye sign, the eyes remain fixed in midposition (good). |
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Patient is unresponsive and pupil's are sluggish when reacting to light, corneal reflexes are diminished, what test did the nurse do to know that the pupil's are sluggish and the corneal reflexes are diminished?
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Patient is unresponsive and pupil's are sluggish when reacting to light, corneal reflexes are diminished, what test did the nurse do to know that the pupil's are sluggish and the corneal reflexes are diminished?
To elicit the corneal reflex, have the patient turn his eyes away from you to avoid involuntary blinking during the procedure. Then approach the patient from the opposite side, out of his line of vision, and brush the cornea lightly with a fine wisp of sterile cotton. Repeat procedure on the other eye. The corneal reflex is automatic closing of the eyelids as a result of irritation of the cornea Absent corneal reflex can increase risk of injury to the eye: apply eye drops or ointment, cover with patch/shield |
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Patient who does not have good corneal reflexes, they are diminished, how are they treated?
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Patient who does not have good corneal reflexes, they are diminished, how are they treated?
Absent corneal reflex can increase risk of injury to the eye: apply eye drops or ointment, cover with patch/shield |
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A nurse is preparing a patient to receive contrast medium prior to a X-ray test, what questions will a nurse ask?
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A nurse is preparing a patient to receive contrast medium prior to a X-ray test, what questions will a nurse ask?
are you allergic to iodine or shellfish, have you had the procedure before, are you pregnant? |
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A client receives contrast medium for the procedure, what kind of teaching does the nurse need to do post procedure?
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A client receives contrast medium for the procedure, what kind of teaching does the nurse need to do post procedure?
flush with at least 1500-3000ml water |
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The patient receives a Lumbar Puncture (Spinal Tap), the client asks “is that needle going into my spinal cord?”, what is the nurse's response?
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The patient receives a Lumbar Puncture (Spinal Tap), the client asks “is that needle going into my spinal cord?”, what is the nurse's response?
No, the needle is going into the subarachnoid space Insertion of a spinal needle into the subarachnoid space between the 3rd and 4th (sometimes 4th and 5th) lumbar vertebrae Used to: obtain cerebrospinal fluid (CSF) readings with a manometer, obtain CSF for analysis, check for spinal blockage due to spinal cord lesion, inject contrast medium or air for diagnostic study, inject spinal anesthetics, and inject certain drugs |
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What clients are a Lumbar Puncture (Spinal Tap) not done on?
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What clients are a Lumbar Puncture (Spinal Tap) not done on?
Because of the sudden release of CSF pressure, a lumbar puncture is not done for clients with symptoms indicating increased intracranial pressure (ICP) |
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What position do you put your patient in, in order to perform a Lumbar Puncture (Spinal Tap)?
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What position do you put your patient in, in order to perform a Lumbar Puncture (Spinal Tap)?
Position the client in the side-lying (lateral) position with hips, knees, and chin flexed toward the chest in order to open the interlaminar spaces; a pillow can be used to support the head or bent over a chair |
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What is the Limbic System?
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What is the Limbic System?
The Limbic System is involved in emotional states and behavior Between the cerebrum and the diencephalon is a region known as the limbic system that links the conscious functions of the cerebral cortex and the automatic functions of the brain stem Hippocampus – learning and long term memory Reticular formation – governs wakefulness and sleep |
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What intervention is most appropriate after a Lumbar Puncture (Spinal Tap) is performed?
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What intervention is most appropriate after a Lumbar Puncture (Spinal Tap) is performed?
After procedure, client is placed in the supine (flat on back) position for several hours (8 or more) Patient is put in supine position to avoid post puncture headache; “Most common complication of lumbar puncture is post puncture headache” “Headache from hell” |
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The nurse is reviewing the client's report of the findings in the Cerebrospinal Fluid (CSF), what would the analysis be? (What are the normal levels in CSF?)
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The nurse is reviewing the client's report of the findings in the Cerebrospinal Fluid (CSF), what would the analysis be? (What are the normal levels in CSF?)
Glucose: 40-80 mg/dL: low glucose level usually is associated with bacterial infection Protein (total): 15-45 mg/dL: high protein levels may occur in demyelinating neuropathies Leukocytes (WBC): 0-5/uL (adults / children); up to 30/uL (newborns): increased WBC’s suggests infection Gross appearance: normal CSF is clear and colorless CSF opening pressure: 50-180 mmHg Culture: sterile Lactate Dehyrogenase: 1/10th of serum level Lactate: less than 35 mg/dL Gram Stain: negative Specific gravity: 1.006-1.009 Syphilis serology: negative Differential 60-70% lymphocytes; up to 30% monocytes and macrophages; other cells 2% or less |
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A client is admitted to the emergency room with throbbing frontal, temporal pain, preceded by visual disturbances, diagnose (What type of Headache?)
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A client is admitted to the emergency room with throbbing frontal, temporal pain, preceded by visual disturbances, diagnose (What type of Headache?)
Migraine Begins as dull ache that progressively worsens and develops into throbbing pulsating pain Unilateral in onset but may become generalized Commonly preceded by a temporary focal neurologic sign known as an aura The classic signs are: nausea, vomiting, photophobia, phonophobia, and aggravated with activity. |
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A client with a migraine is lying in a dark room with a wet cloth over their head after receiving analgesic drugs, what does the nurse do next?
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A client with a migraine is lying in a dark room with a wet cloth over their head after receiving analgesic drugs, what does the nurse do next?
Leave the patient alone |
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A nurse is teaching a client newly diagnosed with migraines about trigger control, what are the migraine triggers?
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A nurse is teaching a client newly diagnosed with migraines about trigger control, what are the migraine triggers?
MSG (Preservatives) Artifical Sweeteners Caffeine Red Wine (Alcohol) Missing Meals Chocolate |
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What are S/S of Migraines?
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What are S/S of Migraines?
Commonly preceded by a temporary focal neurologic sign known as an aura Unilateral in onset but may become generalized Begins as dull ache that progressively worsens and develops into throbbing pulsating pain The classic signs are: nausea, vomiting, photophobia, phonophobia, and aggravated with activity |
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If the mouth is drooping, you might have a problem with which nerve?
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If the mouth is drooping, you might have a problem with which nerve?
Cranial Nerve VII, Facial Nerve - Motor and sensory nerve responsible for movement of the face and scalp and pain, lacrimation (tear formation) and salivation, and temperature of the ear area, deep sensations from the face, and taste from the anterior 2/3 of the tongue. |
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Patient with a head injury having problems with cerebral sensory functions, would probably have problem with the structure that acts as a relay system, what is that?
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Patient with a head injury having problems with cerebral sensory functions, would probably have problem with the structure that acts as a relay system, what is that?
Thalamus – relay station for sensory impulses sorts out the impulses and directs them to other areas of the cerebral cortex. |
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Patient with problems with emotions following a head injury, then the damage would be to the what?
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Patient with problems with emotions following a head injury, then the damage would be to the what?
Limbic System The Limbic System is involved in emotional states and behavior |
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Have a client with a head injury involving the medulla oblongata, you are assessing the client and realize that the medulla oblongata controls what?
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Have a client with a head injury involving the medulla oblongata, you are assessing the client and realize that the medulla oblongata controls what?
Breathing, Pulse rate, Blood vessel diameter Respiratory center – controls the muscles of respiration Cardiac center – regulates rate and force of heart beat Vasomotor – regulates contraction of smooth muscle in the blood vessel walls Medulla oblongata – located between the pons and the spinal cord |
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A client has a cerebellar dysfunction, and they most likely would need assistance with fine muscle movement, an example would be “buttoning shirt, feeding themselves” - explain Cerebellum
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A client has a cerebellar dysfunction, and they most likely would need assistance with fine muscle movement, an example would be “buttoning shirt, feeding themselves” - explain Cerebellum
Made up of 3 parts: the middle portion (vermis) and 2 lateral hemispheres Has an outer area of gray matter and an inner portion that is largely white matter Functions include: Coordinates voluntary muscles Maintains balance Maintains muscle tone |
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A nurse is assessing several clients using the Glasgow Coma Scale, what factors indicate the most serious neurological presentation?
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A nurse is assessing several clients using the Glasgow Coma Scale, what factors indicate the most serious neurological presentation?
Patient whose eyes open only to pain, have abnormal flexion, incomprehensible verbal sounds (Very serious, low Glasgow Coma Scale score) |
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Motor function response in an unconscious patient is purposeful when a nurse applies painful stimuli and the patient pushes the painful stimuli away, that is part of the Glasgow Coma Check.
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Motor function response in an unconscious patient is purposeful when a nurse applies painful stimuli and the patient pushes the painful stimuli away, that is part of the Glasgow Coma Check.
This is an important part of the Glasgow Coma Scale check (better sign than withdrawing from pain) |
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When assessing an unconscious client, what clinical indicator should the nurse expect to identify?
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When assessing an unconscious client, what clinical indicator should the nurse expect to identify?
An inability to control elimination |
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What is a normal finding in a neurological assessment?
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What is a normal finding in a neurological assessment?
PERRLA - pupils equal, round, react to light, accommodation |
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How do you check for a Corneal Reflex?
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How do you check for a Corneal Reflex?
Touch the Cornea lightly with a wisp of cotton. Absent corneal reflex can increase risk of injury to the eye: apply eye drops or ointment, cover with patch/shield |
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If you are trying to assess a diabetic patient for sensory loss (Sensory Function), what do you do?
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If you are trying to assess a diabetic patient for sensory loss (Sensory Function), what do you do?
You need a paper clip to poke their foot It gives the sensation of sharp contact without breaking their skin Assess for pain sensation with any sharp or dull object, such as cotton tipped applicator of paper clip Demonstrate what will be done while client's eyes are open Ask client to close eyes and say whether the touch is sharp or dull; compare reactions on each side of the body If pain and temperature sensations are normal, then touch discrimination is likely to be normal |
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If you are testing a client for touch discrimination, what would be a normal finding?
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If you are testing a client for touch discrimination, what would be a normal finding?
That the client would point at the place at where they are touched (point to the shoulder if touched on the shoulder) Have the client close eyes and touch the client with a finger Ask the client to point to the area that was touched Repeat this procedure on each extremity at random |
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A patient just came back from having a Cerebral Angiography, because the patient demonstrates a complication, the nurse responds in an immediate manner; that complication might be what?
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A patient just came back from having a Cerebral Angiography, because the patient demonstrates a complication, the nurse responds in an immediate manner; that complication might be what?
Bleeding Instruct client to report itching, dyspnea, monitor site for bleeding (flushing and metallic taste is normal) |
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If patient had a Cerebral Angiography and is bleeding, the nurse responds in which manner?
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If patient had a Cerebral Angiography and is bleeding, the nurse responds in which manner?
Nurse responds like it is an emergency |
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Patient has had a general seizure and you are asked to prepare them for a EEG (Electroencephalogram), what is the nursing procedure for a EEG?
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Patient has had a general seizure and you are asked to prepare them for a EEG (Electroencephalogram), what is the nursing procedure for a EEG?
Wash their hair, withhold caffeine and stimulants Painless Avoid CNS depressants or stimulants, no caffeine containing fluids on day of the test Client's hair must be washed on the morning of the test; no sprays or oils Client must wash hair after test to remove electrode glue |
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The parents of a 2 year old reports that their child sometimes stares blankly for just a few seconds and then gets very tired, the nurse anticipates what DX?
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The parents of a 2 year old reports that their child sometimes stares blankly for just a few seconds and then gets very tired, the nurse anticipates what DX?
Absence Seizures More common in children and tends to run in families Consists of brief (often just seconds) periods of loss of consciousness and blank staring as though the person is day dreaming May have automatisms (purposeless motor activity) such as lip smacking, eye fluttering, and picking at clothes |
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What is the priority nursing DX for an Atonic (Akinetic) seizure?
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What is the priority nursing DX for an Atonic (Akinetic) seizure?
Risk for injury related to falls Sudden loss of muscle tone, lasting for seconds, following by postictal (after the seizure) confusion May cause client to fall Resistant to drug therapy |
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A nurse is doing an intake assessment when a client suddenly goes into siezures, what does she do first?
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A nurse is doing an intake assessment when a client suddenly goes into siezures, what does she do first?
Positions patient on side to maintain airway Turn client on side to protect airway |
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A client is being admitted to a room, what equipment is the nurse expected to put in the room for a client ordered seizure precautions?
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A client is being admitted to a room, what equipment is the nurse expected to put in the room for a client ordered seizure precautions?
Oxygen and Suction |
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What is Bacterial Meningitis and what is Nursing considerations?
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What is Bacterial Meningitis and what is Nursing considerations?
An inflammation of the meninges that surround the brain and spinal cord Assessing Neurological status (cranial nerves) every 2 hours S/S: Chills, fever, malaise, petechial purpural rash Headache, vomiting, and papilledema (rarely) Signs of meningeal irritation: nuchal rigidity (stiff neck), positive Brudzinki's and Kernig's signs, opisthotonos Irritability, delirium, deep stupor, coma, photophobia, diplopia, or other vision problems Follow ABC's Take VS and perform neurologic checks every 2-4 hour, monitor for increased ICP |
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When teaching the family with a patient diagnosed with Huntington's Chorea, what should the nurse teach?
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When teaching the family with a patient diagnosed with Huntington's Chorea, what should the nurse teach?
Genetic counseling is important for the children of clients with the disease 50% chance of the disease if one parent has the disease or genetic mutation during sperm development |
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S/S of Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig's Disease
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S/S of Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig's Disease
Amyotrophic lateral sclerosis (ALS) is a terminal neurological disorder characterized by progressive degeneration of nerve cells in the spinal cord and brain Fasciculations (twitching) of the face Dysarthria (slurred speech), impaired chewing, dysphagia, tongue atrophy, fatigue while talking (early signs) Muscle spasticity, atrophy, weakness, and loss of function especially forearms and hands (late signs) Difficulty breathing, reactive depression |
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S/S Huntington's Disease (Chorea)
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S/S Huntington's Disease (Chorea)
Hereditary disorder (genetic) transmitted as an autosomal dominant (only need to get the defective gene from 1 parent to get the disease) trait at the time of conception S/S: personality changes, impaired cognition, balance and coordination problems, clumsiness, involuntary facial movements; sudden jerky, involuntary movements of the body (chorea), slurred speech, dysphagia, dementia |
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What is Multiple Sclerosis (MS)?
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What is Multiple Sclerosis (MS)?
Chronic autoimmune disease that affects the myelin sheath and conduction pathway of the CNS Characterized by exacerbations and remissions Major cause of chronic disability in young adults ages 20-40, and prognosis varies May progress rapidly, disabling the client by early adulthood or cause death within months of onset 70% of clients lead active, productive lives with prolonged remissions |
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S/S of Multiple Sclerosis (MS)
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S/S of Multiple Sclerosis (MS)
Blurred vision, diplopia, nystagmus (often 1st symptom); tremor during activity Gait, balance, and coordination problems Fatigue, weakness, paralysis, spasticity Numbness of the face, body, or extremities Bladder and bowel dysfunction Dizziness, vertigo, cognitive changes Speech impairment, dysphagia (<common) |
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What is Tetraplegia?
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What is Tetraplegia?
Also called quadriplegia, is loss of motor and sensory function involving all 4 extremities |
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Complete transection of the spinal cord at the T6 level?
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Complete transection of the spinal cord at the T6 level?
The prognosis is Paraplegia Paraplegia is loss of motor and sensory function involving only the lower extremities |
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Cranial Nerves
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Cranial Nerves
Cranial Nerve I – Olfactory – Sensory nerve responsible for smell (olfactory receptor cells in the nasal mucosa) Cranial Nerve II, Optic – Sensory nerve (retina) responsible for central and peripheral vision Cranial Nerve III, Oculomotor – Motor responsible for eye movement, lid elevation, pupil constriction Cranial Nerve IV, Trochlear – Motor nerve responsible for turning eye down and inward Cranial Nerve V, Trigeminal – Motor and sensory nerve responsible for chewing; face, scalp, and oral mucosa sensation; corneal reflex Cranial Nerve VI, Abducens – Motor nerve responsible for lateral (outward) eye movement Cranial Nerve VII, Facial – Motor and sensory nerve responsible for movement of the face and scalp and pain, lacrimation (tear formation) and salivation, and temperature of the ear area, deep sensations from the face, and taste from the anterior 2/3 of the tongue Cranial Nerve VIII – Vestibulocochlear – Sensory nerve responsible for hearing and equilibrium (balance) Cranial Nerve IX – Glossopharyngeal – Motor and sensory nerve responsible for swallowing, pain and temperature from the ear, taste and sensations from posterior 1/3 of the tongue and pharynx Cranial Nerve X, Vagus – Motor and sensory nerve responsible for swallowing, speech, gag reflex and pain and temperature from ear, sensations of pharynx, larynx, soft palate Cranial Nerve XI – Accessory – Motor nerve responsible for head movement and shoulder movement Cranial Nerve XII – Hypoglossal – Motor nerve responsible for tongue movement |
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Lobes of the Cerebral Cortex
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Lobes of the Cerebral Cortex
Frontal Lobe – Primary motor area – conscious control of skeletal muscles Parietal Lobe – Primary sensory area – interpretation of touch, pain, and temperature Temporal Lobe – Auditory and olfactory areas Occipital Lobe – Visual receiving and visual association area |
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Autonomic Nervous System
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Autonomic Nervous System
Sympathetic Nervous System – Speeds up the body Parasympathetic Nervous System – Slows down the body |
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Myelin Sheath
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Myelin Sheath – Myelin is a fatty material that insulates and protects the axon nerve fiber
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Types of Neurons
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Types of Neurons
Sensory (afferent) neurons – Carry impulses to the brain Motor (efferent) neurons – Carry impulses from the brain Interneurons (central or associated neurons) – Relay information within the CNS |
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Neurotransmitters
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Neurotransmitters
After a neurotransmitter is released, it must be inactivated Inactivation can be through a reuptake mechanism or by an enzyme that stops the action of the chemical |
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Spinal Nerves
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Spinal Nerves
There are 31 pairs of spinal nerves Cervical Nerves – 8 pairs Thoracic Nerves – 12 pairs Lumbar Nerves – 5 pairs Sacral Nerves – 5 pairs Coccygeal Nerve – 1 pair |
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Communication Areas
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Communication Areas
Wernicke's Area – Speech comprehension (problem: receptive aphasia) (temporal lobe) Brocha's Area (motor speech area) – control of speech muscles in tongue, soft palate, and laryn (problem: expressive aphasia) (frontal lobe) |
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The Brain Stem
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The Brain Stem
Connect the cerebrum and diencephalon with the spinal cord Composed of: midbrain, pons, and medulla oblongata Midbrain – center for certain reflexes involving the eye and ear Pons – carry impulses to and from brain centers located above and below it Regulates respiration, involuntary reflexes |
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If person dresses appropriate to weather, what are you assessing?
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If person dresses appropriate to weather, what are you assessing?
-Reflection of mental status |
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After head injury client expresses change in emotion, what part of brain is involved?
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After head injury client expresses change in emotion, what part of brain is involved?
-Limbic System |
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Head injury involving the Medulla Oblongata?
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Head injury involving the Medulla Oblongata?
-Controls Breathing, Heart Rate, diameter of blood vessels (blood pressure) |
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A person with Cerebellular dysfunction, would most likely need assistance with what ADL's?
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A person with Cerebellular dysfunction, would most likely need assistance with what ADL's?
-Fine Muscle Movements (buttoning a shirt, threading a needle, picking up something) |
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Unconscious patient, can you expect them to be continent?
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Unconscious patient, can you expect them to be continent?
-No |
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Unconscious patient, can you expect them to communicate in any way?
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Unconscious patient, can you expect them to communicate in any way?
-No |
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Neurological assessment on patient involved in traumatic event, what would be normal finding on eyes?
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Neurological assessment on patient involved in traumatic event, what would be normal finding on eyes?
-PERRLA |
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If checking a patient for diabetic neuropathy, what kind of equipment would you use?
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If checking a patient for diabetic neuropathy, what kind of equipment would you use?
-Paper Clip on foot |
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Pt had cerebellar angiography, what is causing nurse to be excited (emergency)?
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Pt had cerebellar angiography, what is causing nurse to be excited (emergency)?
-Bleeding |
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Pt with seizure, going to prepare for EEG, what nursing action is expected?
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Pt with seizure, going to prepare for EEG, what nursing action is expected?
-Wash hair before and after procedure |
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When doing a Lumbar Puncture, where do you place the needle?
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When doing a Lumbar Puncture, where do you place the needle?
-In the subarachnoid space between the 3rd and 4th Lumbar |
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Nurse is delegating tasks, what can be delegated to CNA's (UAP's)?
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Nurse is delegating tasks, what can be delegated to CNA's (UAP's)?
-VS's, ADL's, ROM, Intake/Output, Personal care, cleaning of bed, diapering, moving equipment in room |
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LVN's do not do?
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LVN's do not do?
-Assessments and nursing care plans |
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What do you teach children of patient with Huntington's Chorea?
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What do you teach children of patient with Huntington's Chorea?
-Genetic testing is advisable before having children |
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Patient has severe involuntary twisting movement of the face, limbs, body and deterioration of the intellect and emotion, what do you expect the Dx?
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Patient has severe involuntary twisting movement of the face, limbs, body and deterioration of the intellect and emotion, what do you expect the Dx?
-Huntington's Disease (Chorea) |
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What S/S does the nurse expect to see in a client recently diagnosed with ALS?
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What S/S does the nurse expect to see in a client recently diagnosed with ALS?
-Slowly lose their muscle control (swallowing, breathing), Fasciculations (twitching) of the face, Dysarthria (slurred speech), tongue atrophy, fatigue while talking, dysphagia, atrophy, weakness, fatigue |
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Definition of ALS?
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Definition of ALS?
-ALS is a terminal neurological disorder characterized by progressive degeneration of nerve cells in the spinal cord and brain |
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Client newly diagnosed with MS, what would the nurse need to teach the patient about the pathophysiology of the disease?
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Client newly diagnosed with MS, what would the nurse need to teach the patient about the pathophysiology of the disease?
-Injury to the myelin (demyelination) and the underlying axon - patchy nerve fiber loss and plaque formation that prevents normal nerve conduction - neurologic dysfunction |
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In ALS, what does death occur from?
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In ALS, what does death occur from?
-Typically occurs within 3 years from respiratory failure |
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What do you assess often with patient with ALS?
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What do you assess often with patient with ALS?
- Check breathing (respirations) often |
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With ALS, patient must do this early in the disease when he can still communicate?
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With ALS, patient must do this early in the disease when he can still communicate?
-Advanced Directives |
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28 year old female with MS, what is most important when assisting with ADL's?
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28 year old female with MS, what is most important when assisting with ADL's?
-Fatigue (always a problem with MS patients) |
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Patient with MS, which S/S is expected to be found?
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Patient with MS, which S/S is expected to be found?
-Vision Changes (blurred vision, diplopia, nystagmus (often 1st symptom); tremor during activity |
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Tremors for Parkinson's and MS?
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Tremors for Parkinson's and MS?
-Parkinson's: Tremors at rest -MS: Tremors during activities |
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Injury at T6, what functions will we still have?
-T5 -T4 |
Injury at T6, what functions will we still have? - Breathing (functions of Chest)
-T5 - Maybe no breathing -T4 - No breathing |
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With MS, nurse shouldn't do this?
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With MS, nurse shouldn't do this?
-Don't give hot bath (avoid temperature increases) |
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What is Tetraplegia (quadraplegia)?
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What is Tetraplegia (quadraplegia)?
-Loss of function and senses in all four extremities |
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Patient with autonomic dysreflexia, how do we position patient?
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Patient with autonomic dysreflexia, how do we position patient?
- Put HOB at least 90 degrees (sitting up) |
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Patient with spinal shock (neurogenic shock), what are S/S's?
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Patient with spinal shock (neurogenic shock), what are S/S's?
- low BP (hypotension), bradycardia, flaccid paralysis, bladder distention, loss of reflex activity below the level of the lesion |
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Patient with spinal cord injury, what nursing interventions protect patient from Autonomic Dysreflexia?
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Patient with spinal cord injury, what nursing interventions protect patient from Autonomic Dysreflexia?
-Maintain proper body allignment, log roll technique, monitor for full bladder, fecal impaction or constipation, |
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Patient with full bladder and Autonomic Dysreflexia, what is the nurse going to do?
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Patient with full bladder and Autonomic Dysreflexia, what is the nurse going to do?
-Check urinary catheter tubing for kinks or obstruction, check bladder for distention, check for fecal impaction or constipation, Monitor B/P every 10-15 minutes, place client in sitting position, administer antihypertensives as ordered, notify Dr. |
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Spinal cord injury, what intervention is nurse targeting to prevent Autonomic Dysreflexia?
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Spinal cord injury, what intervention is nurse targeting to prevent Autonomic Dysreflexia?
-Keep body in good alignment, keep bladder empty, make sure they don't get an impaction, monitor skin for pressure sore or ingrown tonail |
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S/S of Autonomic Dysreflexia?
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S/S of Autonomic Dysreflexia?
- Severe, throbbing headache, HTN, flushing above level of lesion, nasal stuffiness |
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Patient with a complete T5 injury, we assess flushed skin, diaphoresis above the T5 injury (sweating), BP 162/96, pounding headache, what do we do?
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Patient with a complete T5 injury, we assess flushed skin, diaphoresis above the T5 injury (sweating), BP 162/96, pounding headache, what do we do? (have autonomic dysreflexia)
-Put HOB 90 degrees (sitting position), loosen any clothing, check bladder and bowel, get Antihypertensive meds, ventilator, check B/P every 5-10 minutes, check urinary catheter for kinks or obstruction |
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Patient with Parkinson's disease, what are we going to do about teaching patient to walk?
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Patient with Parkinson's disease, what are we going to do about teaching patient to walk?
- Do not lean forward - Keep stance wide |
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What is assessment finding when that's most important when developing plan of care with Parkinson's patient?
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What is assessment finding when that's most important when developing plan of care with Parkinson's patient?
-Ability to perform ADL's |
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When Dealing with a Terasoff notification, who is responsible for notifying the threatening person that they are prohibited from purchasing a firearm for 6 months?
A Local Law enforcement B Psychotherapist C Agency having jurisdiction where the victim lives D Department of Justice. |
D. Department of Justice.
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What is the problem when there is injury to Wernike's area?
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What is the problem when there is injury to Wernike's area?
-Receptive aphasia (can't understand speech) (temporal lobe) |
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Low Glasgow Coma Scale?
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Low Glasgow Coma Scale?
-Need for nursing care, because patient is comatose, manage airway, manage patient completely |
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Assessing meningitis, what is positive Kernig's sign?
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Assessing meningitis, what is positive Kernig's sign?
- Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees. |
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What assessment findings in patient with Meningitis?
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What assessment findings in patient with Meningitis?
-Petechial purpural rash, headache, vomiting, nuchal rigidity (stiff neck), positive Brudzinski's (Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed) and Kernig's signs, opisthotonos, photophobia |
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Patient with viral encephalitis, what assessment shows patient is improving?
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Patient with viral encephalitis, what assessment shows patient is improving?
-? |
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Patient has encephalitis, what action by student warrants intervention by nurse?
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Patient has encephalitis, what action by student warrants intervention by nurse?
-? |
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S/S of Parkinson's (four major S/S)?
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S/S of Parkinson's (four major S/S)?
-Rigidity, tremors, bradykinesia or akinesia, and motor or postural instability |
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Patient with parkinson's with mask like face, should be concerned with what?
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Patient with parkinson's with mask like face, should be concerned with what?
- Airway, swallowing, breathing, control of saliva - might need to be evaluated by speech therapist |
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MVA damages cervical spine, altered mental status, extremities are flaccid, what is priority assessment?
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MVA damages cervical spine, altered mental status, extremities are flaccid, what is priority assessment?
-always assess respiratory pattern and airway |
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T5 injury, nursing priority?
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T5 injury, nursing priority?
- T5 or above is respiratory |
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With person with spinal cord injury, what is potential adverse outcome of autonomic dysreflexia?
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With person with spinal cord injury, what is potential adverse outcome of autonomic dysreflexia?
-Hypertensive crisis which leads to Death or stroke |
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complete transection at T6 level, what does patient understand?
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complete transection at T6 level, what does patient understand?
-can breath on their own |