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NSG 239 Final Exam #1 Flashcards | StudBud
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NSG 239 Final Exam #1
NSG 239 Final Exam #1
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1
Pt w/ clear nose drainage post basilar skull fracture, RN test for CSP if fluid is
Grossly bloody and pH is 6
Clumps on dressing and pH is 7
Separates into concentric rings and test positive for glucose
Is clear and tests negative for glucose
2
Complications of Bacterial Meningitis: SATA
Coagulation disorders
Decreased ICP
Increased ICP
Hypertensive coma
Seizures (implement precautions)
Tachycardia
3
What is the difference between viral meningitis and Encephalitis s/s?
Viral meningitis has Altered mental status
Encephalitis has Altered mental status
Encephalitis: Acute inflammation of the brain; usually caused bacteria
Viral meningitis has decreased ICP
4
PAIN AND ANXIETY MANAGEMENT for ICP and CPP: SATA
BENZODIAZEPINES (VERSED)
NEUROMUSCULAR BLOCKING AGENTS (VECURONIUM)
ASPIRIN
DEXMEDETOMIDINE (PRECEDEX)
ACETAMINOPHEN
PROPOFOL (DIPRIVAN)
5
Concussion s/s: SATA
Increased ICP
12-24hrs after injury
Brief disruption in LOC
<5min +LOC = d/c home
6
Headaches Migraines s/s: SATA
Bilateral
throbbing
N/V
Unilateral
7
RNis helping a pt w/ a spinal cord injury to establish a bladder retraining program. Which strategies help? SATA
Tapping the bladder to stimulate the detrusor muscle
Stroking the client's inner thigh
Pulling on the client's pubic hair
Reminding the client to void in a urinal every hour while awake
Initiating intermittent straight catheterization
Pouring warm water over the client's perineum
8
RN INTERVENTIONS TO OPTIMIZE ICP and CPP: SATA
AVOID HIP FLEXION
TRENDELENBURG
AVOID COUGHING, STRAINING, VALSALVA
HOB ELEVATED APPROPRIATELY
QUIET, STIMULATING ENVIRONMENT
PERFORM EXTREME NECK FLEXION SLOWLY
9
Pharmacologic: Abortive Treatment for Migraines: SATA
NSAIDs
Decadron
acetaminophen
TRIPTANS: sumatriptan (Imitrex)
topiramate (Topamax)
Anti-Seizure meds: valproic acid
10
Mannitol — Osmotic diuretics reduce brain volume by drawing free water out of the tissue and into the circulation
True
False
11
Permanent brain damage can occur within ___min of insufficient blood supply
1-3
5-10
10-15
3–5
12
Pt started taking phenytoin to control simplepartial seizures seen in the outpatient clinic.Which is greatest concern?
The white blood cell count is 2300/mm3 (2.3 x 109/L).
The client wants to renew her driver's license in the next month.
The client sometimes forgets to take the phenytoin until theafternoon.
The gums appear enlarged and inflamed.
13
Head Injury and Trauma, Deaths occur in this time range after injury: SATA
Within 2 hours after the injury
Within 48 hours after the injury
3 weeks after the injury
Immediately after the injury
14
Pt w/ meningitis may be uncomfortable, lethargic, or distracted by headache, but their cerebral function remain normal.
True
False
15
Myasthenia Gravis: Antibodies attack cholinergic ACh receptors (AChR) preventing Muscle contraction
False
True
16
Bacterial Meningitis Pharmacologic Treatment IV antibiotics: SATA
Cephalosporins
Vancomycin
Penicillin
Ampicillin
17
Myasthenia Gravis (MG): Assessment SATA
Bilateral eyelid (90%)
breathing: END of day muscle weakness
chewing END of day muscle weakness
Chorea
speaking (voice fading)
Unilateral eyelid (90%)
18
Skull Fracture:◦ CSF detection: Dextrostix or Gauze for halo test
True
False
19
unilateral, intense, sharp/stabbing pain, lasting min-hrs around eye, resulting in tearing (lacrimation), agitated.
Headaches Migraines
Headaches Cluster
Headaches focal
Headaches Tension-type
20
Risk Factors ◦ Measles, chickenpox, mumps, HSV, CMV, West Nile Virus, Amebae
Viral Meningitis
Cerebral Edema
Encephalitis
Bacterial Meningitis
21
Stages of increased ICP: SATA
Stage 1: total compensation
Stage 4: Herniation--> imminent death
Stage 2: widened pulse pressure, bradycardia, irregular respirations
Stage 3: failing compensation; clinical manifestations of ↑ICP :Cushing’s
Stage 2: ↓compensation; risk for ↑ICP
Stage 3: ↓compensation; risk for ↑ICP
22
The most rapid and effective means of decreasing tissue water and brain bulk is osmotherapy.
False
True
23
Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.
Brudzinski's sign
Reiter's syndrome
Wernicke’s Encephalopathy
Kernig's sign
24
Huntington's Disease (HD): Health Promotion/Prevention/Teaching SATA
High calorie diet s/t Chorea using 4k calories/day.
malnutrition
Aspiration, choking precautions
Elevate toilet seat
25
Parkinson's Disease: Characterized by slowness, increased muscle tone and rigidity, tremor at rest, and gait disturbance
True
False
26
Brain Death & Organ Donation Consideration: SATA
Core body temperature >95.6
Coma of unknown cause
SBP >100 mm HG
Neuro exam
27
Multiple Sclerosis (MS) Chronic and Progressive deterioration with remissions and exacerbations
False
True
28
Nursing Interventions: Treat all head injuries like cord injury until proven otherwise
Stabilize Thoracic spine.
ICP >18
Intubate if GCS <8
Pao2 >80 mm Hg
Maintain patient warmth.
MAP >70 mm Hg.
29
Viral Meningitis s/s: SATA
Altered mental status
Fever may be low or moderate
N/ V
headache
30
Bacterial Meningitis s/s: SATA
Pruritis
Hearing loss
Altered Mental status
Petechiae and palpable purpura
Nuchal rigidity (stiff neck)
Fever
31
Phenytoin (Dilantin): Seizure Meds: Only compatible with Normal Saline
True
False
32
Kid is day dreaming.U time event to be 10 sec. After 10 sec, child appropriately responds and doesn’t recall event
Focal Impaired Awareness (complex partial)
Abscence
Tonic-clonic
Atonic
33
NO lumbar puncture if suspected elevated ICP secondary to s/s and/or above 20 mmHg for >5 to 10 minutes
True
False
34
Develop discharge instructions to parent of kid who has atonic seizures. What info is important to include?
“This type of seizure is hard to detect cos child may lk like is daydream
“Be sure your child wears a helmet daily.”
“Its comon for kid to feel extremely tired post this type of seizure.”
“Avoid high fat and low carbohydrate diets.”
35
Status epilepticus: continuous seizure w/out interption cause prolonged +LOC result permeant brain damage EMERGENCY>5min
False
True
36
Most common brain tumors; originate from lung and breast
False
True
37
ICP: Elevated if >20 mm Hg sustained for 5-10mins
True
False
38
Pt w/ recent hx of encephalitis isadmitted w/ new-onset generalized tonic-clonic seizures. RN shud assign LPN/LVN: SATA
Turning the client to his or her side to avoid aspiration
Developing a discharge plan that includes referral to EpilepsyFoundation
Observing and documenting the onset and duration of anyseizure activity
Administering phenytoin 200 mg PO three times a day
Assessing for adverse effects caused by new antiseizuremedications
Teaching the client about the need for frequent tooth brushingand flossing
39
After the nurse receives the change-of-shift report at 7:00 am, whichclient must the nurse assess first?
A 45-year-old pt scheduled for a craniotomy in 30 min, needs pre-op teach
A 59-year-old pt w/Parkinson disease, need a swallow assessment b4 breakfst
A 23-year-old pt w/migraine h/a reports severe nausea associated w/ retchin
A 63yr pt w/ multiple sclerosis, oral temp of 101.8°F & flank pain
40
Increased ICP S/S: SATA
Cushing’s triad (widened PP, bradycardia, irregular RR)Impending herniation
Projectile vomiting w/ nausea
Pupilary changes: fixed; dilated; unilateral pupil -> impending herniation
Hemiparesis/hemiplegia
41
Types of cerebral edema: SATA
Interstitial: tx. Shunt
Vasogenic: tx. corticosteroid
Cytotoxic (cellular): tx. Shunt
Cytotoxic (cellular)
42
Pt now experienc character of a tonic-clonic seizure. started at 1402 and it is now 1408, pt is still in seizure.
Continue to monitor the patient
Restrain the patient to prevent further injury
Suction the patient
Initiate the emergency response system
43
Viral Meningitis: abx after obtain dx sample but b4 receiving test results; continue if found to be viral in nature
False
True
44
Diagnostic Migraines : History! NOT RECCOMMEDNED: Head CT Scan or MRI UNLESS abnormal neuro exam
False
True
45
Spinal Precautions: SATA
Rigid cervical collar
Avoid HOB elevation (may do modified Trendelenburg)
Bedrest
Avoid HOB elevation (may do reverse Trendelenburg)
Log roll
Avoid neck flexion
46
RN teaching the pt w/ MG about prevention of myasthenic & cholinergic crises. RN tells pt its most effectively done by:
Doing muscle-strengthening exercises
Doing all chores early in the day while less fatigued
Eating large, well-balanced meals
Taking medications on time to maintain therapeutic blood levels
47
Requires rapid evacuation to prevent herniation ◦ Medical Emergency: usually arterial bleed
Epidural Hematoma
Contusion
Subdural Hematoma
Laceration
48
Headaches Tension-type s/s: SATA
N/V Prodrome symptoms
Stress; Female; Neurovascular
mild-moderate pain
Photophobia; phonophobia
Bandlike; Bilateral
Constant dull pressure;
49
May take a missed seizure med dose within
30 min
24 hrs
1 hr
48 hrs
50
Traumatic Brain Injury (TBI) GCS SCORE: SATA
Moderate (GCS 9-12) 60min-6hrs LOC
Minor (GCS 13-15) <30min LOC
Severe (GCS 2-8) >6hrs LOC
Minor (GCS 9-13) <20min LOC
Moderate (GCS 9-12) 30min-6hrs LOC
Severe (GCS 3-8) >6hrs LOC
51
Which pt in the neuro ICU should thecharge nurse assign to an RN who has been floated from themedical unit?
46yr pt admitted 48 hrs ago w/bacterial meningitis and has antibiotic due
26-year client with a basilar skull fracture clear drainage out of nose
42yr client admit several hrs ago w/ a h/aa dx of a ruptured berry aneurysm
65yr pt w/ an astrocytoma just returned to unit after crani
52
You asses ur pt load for the pts who are at Greatest risk for seizures. SATA
A 1-year-old who is post opt day 5 from open bowel surgery.
A 32-year-old with a blood glucose of 20 mg/dL.
A 16-year-old with bacterial meningitis.
A 63-year-old whose CT scan shows an ischemic stroke.
A 72-year-old who is post opt day 5 from open heart surgery.
A 58-year-old experiencing ETOH withdrawal.
53
RN is positioning pt with increased ICP, Which position should RN avoid?
Neck in neutral position
Head turned to the side
Head midline
HOB elevated 30-45 degrees
54
Highest mortality often goes unrecognized #venous
Contusion
Subdural Hematoma
Subarachnoid hemorrhage
Epidural Hematoma
55
RN interventions to lower ICP: SATA
propofol
Hypertonic saline bolus doses
Isotonic saline bolus doses
Elevate HOB
56
Post concussion Syndrome s/s: SATA
occurs 2wks-2mth later
Retrograde amnesia
Changes in intellectual ability
Decortication or Decerebration
57
Encephalitis: Health Promotion/Prevention/Teaching: SATA
Mosquito/ Tick control
ROM exercises and warm baths for muscle rigidity
Vaccines
Avoid pool swimming
58
For a male with increased ICP, a most appropriate respiratory goal is to
Lower Arterial pH
Maintain partial pressure of arterial O2 (PaO2) of >80 mm Hg
Prevent Respiratory Alkalosis
Promote CO2 elimination
59
MG:Acute exacerbation:muscular, resptory,bulbar wkness trigered by infectn, sx, emotional distress, or inadequate drugs.
False
True
60
Pt admitted w/ bacterial meningitis c/o of severe h/a w/ photophobia, a temp of 102.60 F orally. What to do first?
Give acetaminophen (Tylenol) 650 mg orally to reduce the fever.
Administer codeine 15 mg orally for the patient’s headache
Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection
Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.
61
Indications for ICP: SATA
Glasgow Coma Scale of ≤3
Glasgow Coma Scale of ≤8
Abnormal CT scans or MRI
Abnormal CT scans or X-ray
62
Scalp Lacerations: Major complications – blood loss and infection
False
True
63
Ominous signs: Cushing’s Triad : SATA
Tachycardia
irregular respirations
bradycardia
widened pulse pressure
64
WEANING ANTI-SEIZURE MEDS MAY OCCUR IF 2-5YR SEIZURE FREE; NEURO EXAM AND EEG (WNL)
True
False
65
Huntington's Have excess Dopamine and decreased ACh, psychiatric s/s occur before movement issues
True
False
66
Your patient is scheduled for an EEG (electroencephalogram). As the nurse you will:*
Keep the patient nothing by mouth.
Allow the patient to have coffee, milk, and juice only.
Administer a sedative prior to the test.
Transport in semi-lunar position
Hold seizure medications until after the test
Wash the patient’s hair prior to the test.
67
Diffuse intrinsic pontine glioma
is a brain tumor that is highly aggressive, difficult to treat. occurs in brainstem
False
True
68
Dopaminergic:Parkinson's Disease SATA
sertraline
tetrabenazine
amantadine
Benztropine
Levodopa
Bromocriptine
69
Craniotomy management: SATA
Frontal lobe tumors: personality changes
Supratentorial : HOB >30 degrees
Infratentorial: HOB <10 degree , only side lying the 1st 48hrs, strict NPO
Lumbar puncture for reduction of herniation
70
Metabolic disturbances for seizures: SATA
Alkalosis
Hyperglycemia
Alcohol or barbiturate withdrawal
Acidosis
Hypoglycemia
water intoxication only
71
Craniotomy RN post-op care: SATA
Keep HOB supine
Neuro assessment every 15- 30 mins for 6 hrs-> every hr for 24hrs.
Monitor for ICP changes
Monitor dressing: Report saturation or >50ml in 8hrs
72
NG placement in Basilar skull Fracture MUST be placed under Fluoro
True
False
73
PT w/cervical spinal cord injury, placed in fixedskeletal traction w/ halo fixation device. assign to LPN/LVN: SATA
Developing the nursing plan of care for the client
Administering oral medications as ordered
Assessing the client's neurologic status for changes
Cleaning the halo insertion sites with hydrogen peroxide
Observing the halo insertion sites for signs of infection
Checking the client's skin for pressure from the device
74
Basilar Skull Fracture: Battle's sign (postauricular ecchymosis) & Racoon Eyes (periorbital ecchymosis)
True
False
75
Purulent secretions spread to other areas of brain through CSF.
Viral meningitis
Bacterial meningitis
All Neurological alterations
Both Viral and Bacterial meningitis
76
Cerebral Damage S/S: SATA
Appearance of Tachycardia
Abnormal breathing patterns: Cheyne–Stokes
•Evidence of extra ocular movement abnormalities
Extensor plantar response
Abnormal breathing patterns: Stridor
Decrease in blood pressure
77
Rare, progressive degenerative disease involve loss of motor neurons:Lead to death w/in 2 – 6 yrs after dx (trapped in)
Huntington's Disease (HD)
Amyotrophic Lateral Sclerosis (ALS)
Myasthenia Gravis (MG)
Multiple Sclerosis (MS)
78
Bacterial Meningitis: Diagnostic: SATA
verified by lumbar puncture and sample of CSF: Culture and Gram stain
urine cultures
CT scan: Prior to LP if suspect elevated ICP
Blood culture
79
Malignant and Invasive: deadly Brain Tumor
Glioblastoma Multiforme
Craniopharyngioma
Acoustic Neuroma
Meningiomas
80
Viral Meningitis: Isolate & droplet precaution immediately until etiology determined #Self-limiting
True
False
81
Brain Tumor: Pharmacologic Treatment : SATA
Temozolomide
High dose corticosteroids → Dexamethasone
Codeine w/o sedation
Keppra (levetiracetam)
82
Huntington's Disease (HD) Death from : SATA
MI
Common cold
Pneumonia
Suicide
83
Diffuse Axonal Injury (DAI) s/s: SATA
12-24hrs after injury
Personality and behavior changes
90% in a persistent vegetative state
Decreased LOC
84
Which client shud charge RN assign to travelnurse, new to neurologic unit, who has been on the neurologic unit for 1wk
A 34-year-old client with newly diagnosed multiple sclerosis (MS)
A 25-year-old client admitted with a C4-level spinal cord injury (SCI)
A 68-year-old client with chronic amyotrophic lateral sclerosis (ALS)
A 56-year-old client with Guillain-Barré syndrome (GBS) in resp distress
85
Headaches durations: SATA
Tension-type (Intermittent for weeks; months; yrs (lasting minutes or days)
Tension-type (Intermittent for days; weeks; mnths (lasting minutes or days)
Migraines (4 to 72 hours)
Cluster (8xday lasting minutes-hrs) for weeks/mths
86
Bacterial meningitis is a medical emergency
False
True
87
Social effects of chronic neurologic disease include SATA
Job loss
Depression
Divorce
Role changes
Loss of self-esteem
All of the Above
88
Encephalitis: Pharmacologic Treatment
Acyclovir
codeine
Anti-Seizure meds
Cephalosporins
89
Rilutex (antiglutamate): Slows progression of ALS by decreasing amount of glutamate – LIMIT alcohol consumption
False
True
90
CPP >50 MM HG IS ASSOCIATED WITH ISCHEMIA AND NEURONAL DEATH
False
True
91
Symptoms and signs of meningeal irritation (photophobia and nuchal rigidity) are usually absent with a pure encephalitis
True
False
92
Most common causes of neurological alterations are viral illness
True
False
93
most common type of migraine
Migraine without Aura
Unilateral
Bilateral
Migraine with Aura
94
Immediate medical care if: SATA
The event is a first-time seizure
Significant bodily harm occurs
Status epilepticus occurs Seizure lasting >5mins or without breaks
DIPLOPIA
95
Myasthenia Gravis Health Promotion/Prevention/Teaching: SATA
schedule drugs to peak at mealtime, avoid fatigue, recognizing crisis
mechanical soft diet
Balanced diet
Schedule activities 45mins before med administration
96
Parkinson's Disease: Absorption of levodopa may be impaired by protein and vit B6 (GIVE DRUGS BEFORE MEALS)
False
True
97
Gold Standard for measuring ICP?
Catheter inserted into lateral ventricle
Ventriculostomy
Can control ICP by removing CSF (ONLY with ventricular catheter).
Coupled with an external transducer
98
The client is suffering from a migraine headache. What is an appropriate nursing intervention?
Give antibiotics
Give narcotic analgesics.
Provide a dark, quiet room
Recommend Head CT
99
Pt w/glioblastoma on dexamethasone 4 mg IV push q6 to relieve s/s of R arm weakness and h/a.Which info concerns RN most?
The daily weight has increased 2.2 lb (1 kg).
The blood glucose level is 234 mg/dL (13 mmol/L).
he client reports a continuing headache.
The client no longer recognizes family members.
