question

Categories of the Glasgow Coma Scale

answer

Eye opening Motor response Verbal response

question

Criteria for determining brain death

answer

Pupils fixed Apnea Reflexes absent No response to pain Flat EEG Absent cerebral blood flow

question

components of the skull

answer

Brain tissue Blood CSF

question

Signs of Cushings Triad

answer

Widening pulse pressure Increased systolic B/P Bradycardia Decreased respirations

question

Steps to follow when checking responsiveness of a patient with decreased LOC

answer

alert verbal pain unresponsive

question

Accepted painful stimuli for patient with decreased LOC

answer

Sternal rub Supraorbital pressure Pinch fleshy part of upper arm Pressure on nail beds

question

Terms used to describe LOC

answer

Fully conscious Confused Lethargic/obtunded stuporous comatose

question

Labs tests used to diagnose cause of decreased LOC

answer

glucose sodium serum osmolality ABGs Toxicology screening CBC

question

Examples of activities causing increased intracranial pressure

answer

Cough Sneeze Bearing down/Valsalva

question

Early signs and symptoms of IICP

answer

Headache Nausea Decreased LOC Vomiting

question

Normal range for intracranial pressure

answer

5-15 mmHg

question

Nursing considerations for patient on mannitol

answer

1) monitor for fluid overload 2) use filter 3) monitor urinary output 4) monitor renal infection 5) contraindicated for decreased or no urine output

question

Methods to measure intracranial pressure

answer

intraventricular catheter (ventriculostomy) subarachnoid screw epidural sensor

question

Nursing care for a patient receiving phenytoin

answer

good mouth care monitor for gingival hyperplasia monitor drug level (10-20)

question

Characteristics of CPP

answer

CPP normally 60-110 mmHg CPP = MAP - ICP < 50 = ischemia <30 = death

question

Side effects of glucocorticoids

answer

GI bleeding infection hyperglycemia increased B/P

question

Interventions to help decrease IICP

answer

raise HOB 30-40 degrees hyperventilate - CO2 level 30-35mmHg hypothermia/thorazine surgery

question

characteristics of MAP

answer

needs to be 60 or greater 70-110 mmHg is normal organ dysfunction occurs if <60 mmHg

question

Dietary consideration if on MAOIs and have parkinson's disease

answer

-avoid tyramine (cheeses, especially aged; cured, smoked or processed meats; pickled or fermented foods; alcohol, dried fruit, anything that is or might be spoiled) -High fiber to avoid constipation (common problem)

question

Dietary consideration if on MAOIs and have MS

answer

nothing special, stay healthy to avoid relapses

question

Dietary consideration if on MAOIs and have IICP

answer

watch for fluid overload, can increase ICP

question

A nurse is teaching a client who has multiple sclerosis about starting therapy with baclofen (Lioresal). Which of the following instructions should the nurse include?

answer

Avoid driving until the drug's effects are evident.

question

A nurse is presenting discharge instructions to a client who has multiple sclerosis. The client reports symptoms of diplopia and sensory change. Which of the following nursing statements are appropriate?

answer

Implement a schedule to include periods of rest.

question

A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform?

answer

Position the patient upright during feeding

question

A 33-year-old patient presents with weakness, incoordination, dizziness, and loss of balance. The patient is diagnosed with MS. What are typical initial S&S of MS?

answer

Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

question

The nurse is creating a care plan for a patient with a recent diagnosis of MS. Which of the following should the nurse include in the patient's care plan?

answer

Instruct the patient on daily muscle stretching

question

A nurse is caring for a client who was admitted to the hospital after having two seizures at work. The client suddenly gives a short cry and stiffens. Which of the following should be the initial nursing action?

answer

Make a mental notation of the time after looking at a watch.

question

A patient is due to arrive in the emergency room with a seizure that has been going on for at least 6 minutes. The nurse receiving the patient knows that the following medications must be prepared: (select all that apply)

answer

Intravenous lorazepam Dextrose 50%

question

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.)

answer

Loosen restrictive clothing. Place a pillow under the client's head.

question

A nurse is creating a plan of care for a client who has a tonic-clonic seizures disorder. Which of the following seizure precautions should the nurse implement? (Select all that apply.)

answer

A) Provide a suction setup at the bedside. B) Elevate the side rails when in bed. C) Place the bed in the lowest position. D) Keep an oxygen setup at the bedside.

question

A nurse is caring for a patient with a suspected diagnosis of bacterial meningitis. Which of the following is a priority action for the nurse to take?

answer

Place the patient in isolation.

question

A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate finding by the nurse?

answer

Severe headache

question

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

answer

Brudzinski sign

question

A nurse is admitting a client who has bacterial meningitis. The nurse notes during the physical examination that the client cannot extend his leg when his hip is flexed so that his thigh rests on his abdomen. The nurse should document this as which of the following?

answer

Kernig's sign

question

A community health nurse is caring for a patient with complaints of a headache and a stiff neck. Which of the following actions should the nurse perform first?

answer

Check the client's temperature.

question

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

answer

Inability to recognize his family members

question

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

answer

Establish the ability to communicate effectively.

question

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

answer

Remind the client to look for food on the left side of the tray.

question

A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?

answer

Limit questions to yes and no answers.

question

A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this patient?

answer

The patient should be approached on the side where the visual perception is intact.

question

A nurse is implementing a plan of care for a client who has a cerebral aneurysm. Which following nursing measures should the nurse implement?

answer

Encourage exhaling through mouth when defecating.

question

A nurse is implementing a plan of care for a client who had a craniotomy to clip a cerebral aneurysm. Which of the following postoperative complication should the nurse anticipate?

answer

Polyuria

question

A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed a monoamine oxidase inhibitor (MAOI). Which of the following foods should the nurse eliminate?

answer

Cheese

question

A nurse notes a client who has Parkinson disease shows signs of dyskinesia. Which of the following physical manifestations should the nurse expect?

answer

difficulty moving

question

A nurse is caring for a patient who has Parkinson's disease and is to start taking diphenhydramine (Benadryl) 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see when evaluating the patient's response to diphenhydramine?

answer

decreased tremors

question

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

answer

Bradykinesia

question

A nurse is performing an initial assessment on a person suspected of having PD. When is the best time to assess for the presence of a tremor?

answer

when the patient is resting

question

A patient with Parkinson's disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The patient's nutritional needs should be met by what method?

answer

Semisolid food with thick liquids

question

An emergency department nurse is caring for a client who has an epidural hematoma following a motor vehicle crash. Which of the following is an expected finding?

answer

Alternating periods of alertness and unconsciousness

question

An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. When performing a neuro exam, which of the following is the most reliable indicator of cerebral status?

answer

LOC

question

A nurse is planning preventative care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following is an appropriate nursing action?

answer

reduce stimuli

question

Which would be the earliest indication that a patient may be experiencing ICP?

answer

restlessness

question

A client has increased intracranial pressure following a closed-head injury. The nurse should recognize which of the following interventions as contraindicated for this client?

answer

Cough and deep breathe.

question

The nurse knows that a manifestation considered an early indication of increased intracranial pressure (ICP) is

answer

lethargy

question

A nurse is caring for a client who has just had an evacuation of a subdural hematoma following a head injury. Which of the following is the nurse's highest priority assessment?

answer

Respiratory status

question

A nurse is caring for a client following surgical treatment for a supratentorial brain tumor. Which of the following interventions should the nurse take?

answer

Notify the provider for drainage greater than 80 mL/8hr.

question

Who is most likely to experience autonomic dysreflexia?

answer

A person with a T-4 level spinal cord injury with constipation

question

Which vital sign would be of the greatest concern for a person with C-4 level SCI?

answer

Resp - 28

question

Why is it very important for corticosteroids to be given within 8 hours of a sci?

answer

To help prevent further damage from occurring to the spinal cord

question

Which medication would be typical for a person with a SCI?

answer

Baclofen

question

After a person with a possible spinal cord injury has been stabilized, what needs to be done next?

answer

Obtain a cervical spine x-ray

question

What is the highest level of function a person with a C-5 level SCI could do?

answer

Operate an electric wheelchair with mobile hand supports

question

Which intervention would be most helpful for a spinal cord injured patient who experiences orthostatic hypotension?

answer

Wear an abdominal binder

question

Which would be a sign of autonomic dysreflexia in a person with a SCI at level T-6 or above?

answer

Pounding headache

question

What is the first intervention the nurse would do for a patient with an elevated b/P who is experiencing autonomic dysflexia?

answer

Raise the head of the bed

question

What is important to check Before giving nifedipine to a person experiencing autonomic dysreflexia?

answer

If the person is taking a PD5 inhibitor

question

Which intervention is appropriate for a person in cervical traction?

answer

Keep the traction in place 24 hours a day

question

Produced by the adrenal cortex and have an anti-inflammatory effect

answer

corticosteroids

question

Taken orally or enema to decrease potassium level

answer

sodium polystyrene sulfonate

question

Phosphate binder

answer

sevelamer

question

Synthetic vitamin D

answer

Calcitrol

question

Used to treat metabolic acidosis

answer

sodium bicarb

question

Stimulates production of red blood cells

answer

epoietin alpha

question

Helps boost production of RBCs; should not be taken with milk

answer

iron supplements

question

Antihypertensive that can cause increased potassium levels

answer

ACE inhibitors

question

Causes relaxation of smooth muscle promoting urination in patient with BPH

answer

alpha-1 adrenergic antagonists

question

Used to treat prostate hyperplasia

answer

5-alpha reductase inhibitors

question

Reduces muscle spasms of bladder and urinary tract

answer

oxybutynin

question

Reduces bladder spasms and controls pain

answer

B&O supp

question

Used in treatment of erectile dysfunction

answer

PDE 5 inhibitors

question

Draws ammonia from blood into the colon and expels ammonia with stool

answer

lactulose

question

Antibiotic that stops the production of bacteria that produce ammonia

answer

rifaximin

question

Causes vasodilation of portal circulation decreasing risk of bleeding of esophageal varices

answer

octreotide

question

Potassium sparing diuretic

answer

spironolactone

question

Treats Hep C.; monitor for infection and anemia

answer

Peginterferon and ribavirin

question

Cures certain types of Hep C

answer

ledipasvir-sofdouvir

question

Adrenal corticosteroid inhibitor; monitor for hypotension

answer

aminoglutethimide

question

Antifungal agent that is corticosteroid inhibitor; monitor liver enzymes

answer

ketoconazole

question

Osmotic diuretic

answer

mannitol

question

Used in the long-term treatment of seizures

answer

phenytoin

question

Steroid used to treat cerebral edema

answer

dexamethasone

question

Anti-psychotic med that helps to prevent shivering when using cooling blanket for patient with IICP

answer

chlorpromazine

question

Used to increase dopamine level of person with PD

answer

levodopa-carbidopa

question

IV drug used for emergency treatment of seizures

answer

fosphenytoin

question

IV drug used to immediately stop seizure of person with status epilepticus

answer

lorazepam

question

High doses of this med is used to treat GBS

answer

immunoglobulin

question

Used to treat nerve pain

answer

gabapentin

question

Used to help prevent DVTs

answer

enoxaparin

question

Med used in a test to confirm the diagnosis of MG

answer

endrophonium

question

Used to treat person in cholinergic crisis

answer

atropine sulfate

question

Given 30-45 minutes before meals for person with MG

answer

_pyridostigmine and neostigmine

question

Slows the progression of ALS; check liver enzymes

answer

riluzol

question

Muscle relaxer used in conditions such as MS

answer

baclofen

question

Suppress action of adrenal cortex; monitor for hepatotoxicity and shock

answer

miotane

question

Suppress action of adrenal cortex

answer

metyrapone

question

Blocks the action of cortisol; used for persons with diabetes

answer

mifepristine

question

Replaces glucocorticoids after adrenalectomy

answer

hydrocortisone

question

Replaces aldosterone after adrenalectomy

answer

fludrocortisone

question

Given preop to a person with pheochromocytoma to prevent hypertensive crisis during surgery

answer

alpha and beta blockers

question

Urinary analgesic

answer

phenazopyridine

question

what is the most sensitive music for ICP

answer

LOC: agitation, lethargy, irritability

question

what are the three methods for monitoring ICP

answer

intraventricular catheter suparchnoid screw epidural sensor

question

how is cpp calculated

answer

MAP-ICP

question

Normal MAP

answer

70-100

question

normal ICP

answer

5-15

question

Normal CPP

answer

60-100

question

what does it mean if the CPP is less than 50

answer

ischemia occurs

question

incompatible with life occurs with a CPP

answer

less than 30

question

how would you assess the accessory nerve (cranial nerve XI)

answer

ask the person to shrug

question

why is IV lorazapam and diazepam given to someone experiencing status epilepticus

answer

to stop it

question

why is phenytoin given to someone experiencing status epilepticus

answer

long term therapy maintenance

question

why is dextrose 50% given to someone experiencing status epilepticus

answer

increase blood sugar

question

what type of information is important for a nurse to chart after a patient has a seizure

answer

time started, duration, aura occured, meds given, was LOC lost, ant intervention done

question

what would be an appropriate nursing problem during recovery phase after a seizure

answer

Altered mental status

question

what interventions and assessments would be important for a person with a head injury: Respiratory

answer

patent airway O2 above 92% side lying

question

what interventions and assessments would be important for a person with a head injury: Neuro

answer

HOB 15-45 degrees seizure precautions assess cerebral fluid leak Glasgow Coma scale CPP

question

what interventions and assessments would be important for a person with a head injury: Pain

answer

no morphine!!!

question

what is the purpose of an EEG and what meds and substances should be avoided before EEG

answer

-measures electrical activity of brain -don't give stimulant, tranquilizers, anticonvulsants, opiods

question

what are important interventions or signs associated with phenytoin Hygiene

answer

good oral to avoid hyperplasia floss, brush teeth after meals

question

what are important interventions or signs associated with phenytoin Blood levels

answer

10-20 check periodically for toxicity

question

what are important interventions or signs associated with phenytoin: What solution to mix with

answer

NS only no D5W or it will crystallize

question

what are important interventions or signs associated with phenytoin Urine color

answer

red/pink this is normal

question

an 83 yo woman was diagnosed with ALzheimers disease 2 years ago and the disease has progressed at an increasing pace in recent months. The patient has lost 16 pounds over the past 3 months, leading to a nursing diagnosis of Imbalanced nutrition: less than body requirements. What intervention should the nurse include in this patients plane of care?

answer

Offer the patient only one food item at a time to promote focused eating

question

A nurse is caring for a client who has dementia due to Alzheimers disease and was admitted to a long-term care facility following the death of her partner 40 years The client states I want to go home; my husband is waiting for me to cook dinner. Which of the following responses by the nurse is appropriate

answer

Tell me what you like to cook for dinner

question

why a persons with MS more at risk of getting a UTI? what can be done to help prevent this

answer

Incomplete emptying of bladder -Straight cath every 4 hours, encourage fluids, cranberry pills

question

what are general interventions that would help a person with hepatitis

answer

rest and nutrition

question

what substance in the blood causes a person with cirrhosis to develop hepatic encephalopathy

answer

ammonia

question

what position is to be avoided for a person with pancreatitis

answer

flat lying

question

what is the most common complication after cholecystectomy

answer

respiratory

question

what are important considerations when administering CBI after a TURP: Type of fluid

answer

saline

question

what are important considerations when administering CBI after a TURP: complication

answer

Transurethral resection TUR: observe the fluid --hyponatremic

question

what are important considerations when administering CBI after a TURP: rate of fluid

answer

based on color: want it to be a light pink if it is red increase the rate if it is clear decrease the rate

question

what are important considerations when administering CBI after a TURP: measuring fluid

answer

total output - amount of irrigant

question

A female patient is diagnosed with right sided stroke The patient is now experiencing hemianopsia. how might the nurse help the patient manage her potential snesory and perceptual difficulties

answer

Place the patients extremities where she can see them

question

a patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what

answer

Evidence of a hemorrhagic stoke

question

what is the most common complication of someone having hemodialysis

answer

hypotension

question

what is the most common complication for someone having peritoneal dialysis

answer

infection (peritonitis) cloudy dialistate

question

How do you protect AV fistula

answer

no BP or sticks in that arm no tight clothes no lifting with that arm

question

How do you monitor patency with AV fistula

answer

feel the thrill hear the bruit

question

what effects do glucocorticoids have on a person: Glucose metabolism

answer

decreases metabolism and increase sugar

question

what effects do glucocorticoids have on a person: Healing

answer

slows down

question

what effects do glucocorticoids have on a person: Infection

answer

increases risk

question

what effects do glucocorticoids have on a person: Fat metabolism

answer

decreases so collects fatty tissue

question

what effects do glucocorticoids have on a person: Protein metabolism

answer

increases so thin extremities and bones are fragile

question

What effects does aldosterone have on a person

answer

Urine output- decreases Sodium- increased Potassium- decreases BP- increases

question

What effect does amount of stress have on the dose of hydrocortisone to be given to a person with Addisons disease

answer

need more meds mild to moderate double the meds severe triple the meds

question

what are characteristics of addisons disease

answer

Sodium- decreases Potassium- increases Fluid volume- decreases

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