Autonomic Dysreflexia NCLEX Questions Nurse Sarah, Sympathetic vs. Parasympathetic Nervous System Quiz - Includes Pharmacology nurse Sarah, Nurse Sarah lecture 1, Ch 63 Management of Patients with Neurologic Trauma, Chapter 19- Management of Patients...

frontal lobe functions

"Executive functions" Planning, inhibition, concentration, orientation, language, abstraction, judgment, motor regulation, mood. Lack of social judgment is most notable in frontal lobe lesion. ("D amage = D isinhibition" - e.g., Phineas Gage) person's affect, judgment, personality, and inhibitions

Autonomic Dysreflexia

(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)

guillain barre syndrome complications

*respiratory failure* which can lead to the need for mechanical ventilation, residual numbness, blood pressure fluctuations, cardiac arrhythmias, neuropathic pain, sluggish bowel function, urine retention, blood clots, pressure sores

pneumonia risk factors

- Advanced age - Lung diease - Smoking - Immuno suppressed - Bed riddin - Post- Op - hf, dm, alcoholism, copd, aids, influenza, CF

Sarcoidosis management

- Corticosteroids! (tends to affect the lungs)

Increased Intracranial Pressure (ICP)

- Early signs and symptoms may be subtle - As pressure increases, signs and symptoms become more pronounced and the level of consciousness (LOC) deteriorates

S/S of pleural effusion

- Fever, chills, pleuritic pain, dyspnea (large effusion) ❖Decreased or absent breath sounds; decreased fremitus; and a dull, flat sound on percussion ❖May have tracheal deviation away from affected side

head injury management 1

- Glucocorticoids to treat oedema - ABs to decrease risk of infection - Surgery to decrease ICP - Blood products and o2 to protect remaining tissue

vap bundle

- HOB 30-45 degrees - interrupt sedation daily to assess readiness to wean - provide daily oral care with chlorhexidine - provide prophylaxis for DVT and PUD

lung abscess nursing management

- Monitor V.S, LOC, and respiratory status for any signs of hypoxia. - Broad-spectrum antibiotic coverage is necessary because of mixed bacteria in an abscess. - Clindamycin is first-line therapy. Teach patient to cough effectively - Chest physiotherapy and postural drainage are not recommended because they may cause spillage of infection into other bronchi, extending the infection. - Dental care

TBI assessment

- Timing of injury - Cause/mechanism of injury - Loss of consciousness? How long? - Glasgow coma scale - Neuro assessment

steroids adverse effects

- administer before 0900 or every other day - adrenal insufficiency and withdrawal so TAPER OFF - Osteoporosis (taken for long time, take CALCIUM AND VITAMIN D) - infection due to immunosuppression - glucose intolerance (in diabetics so give insulin for hyperutremia) - Fluid & electrolyte imbalance - growth retardation (high dose for long time) - appetite stimulate - no emotional control - thinning of skin (paper skin) - latrogenic cushing syndrome (having too much steroid but comes w med, risk ration) - fluid retention - myopathy (usually proximal) po= weight gain, irritation immunosuppression

water seal chamber

- chest tube chamber that provides a one-way valve so that air leaves and cannot reenter chest - bubbling is normal initial 48 to 72 hours - tidaling (expected to rise with inspiration, fall with exhalation)

S/S of atelectasis

- dyspnea - cough - sputum production

ICP nursing management

- elevate the head of the bed as prescribed (gravity helps drain fluid) - maintain head/neck in neutral alignment (no twisting or flexing) - give sedation as ordered to prevent agitation - avoid noxious stimuli (scatter procedures so that client does not become overtired).

pneumonia pt care

- fluid 2-3L/day -High fowlers - for hypoxia, good lung down - ambulate after 8hrs postop -incentive spirometer qhr. - cool mist humidifier at night

Acute Tracheobronchitis s/s

- intially dry cough w mucus/ sputum progressed: dyspnea, stridor, wheezes, purulent sputum

Decorticate posturing

-"flexor posturing" or "mummy baby" (think Egyptian mummy preservation) -adduction of arms (arms fold to chest); flexion of elbows and wrists the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

Autonomic Dysreflexia nursing interventions

-**elevate head, sit upright -sitting upright will help lower blood pressure by inducing pooling of blood in the abdominal and lower extremity vessels -assess for and remove cause i.e immediate catherterization, remove stool impaction if cause, remove constrictive clothing -monitor and treat BP

meningitis management

-ABCs -control ICP with antipryetics, re positioning, or drain -antimicrobial therapy ASAP -monitor I and O/electrolytes -comfort measures like low lights, quiet, minimal stimulation -seizure precautions

aspiration nursing interventions

-Keep HOB elevated >30 degrees -Avoid stimulation of gag reflex with suctioning or other procedures -Check for placement before tube feedings -Thickened fluids for swallowing problems: soft diet, small bites, no straws

ARDS Complications

-Multiple-organ dysfunction syndrome -Renal failure -Disseminated intravascular coagulation -Long-term pulmonary effects associated with high oxygen and other therapies Lung damage Oxygen dependent

sarcoidosis assessment

-Night sweats -Fever -Weight loss -Cough and dyspnea -Skin nodules -Polyarthritis -Kveim test: Sarcoid node antigen is injected intradermally and causes a local nodular lesion in about 1 month.

ARDs risk factors

-Sepsis (33% of cases) -Aspiration of gastric contents -Shock -Infection -Trauma -Toxic inhalation -Near drowning -Multiple blood transfusions

Autonomic Dysreflexia/Hyperreflexia

-acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in normal people. - occurs only after spinal shock has resolved. - S/S= severe, pounding headache with paroxysmal hypertension, profuse diaphoresis (most often of the forehead), nausea, nasal congestion, and bradycardia. - occurs w pts w cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided - TX= place immediately in a sitting position to lower BP

lung abscess risk factors

-impaired cough and glottis reflexes, - impaired swallowing, CNS disorders (e.g., seizure or stroke), -drug addiction, alcoholism, - esophageal disease, - immunocompromised, - those without teeth, those receiving NG tube feedings -altered LOC due to aesthetics

TB s/s

-persistent cough >3 weeks -chest pain -weakness -anorexia -hemoptysis (coughing up blood) -dyspnea -fever -night sweats -chills - fatigue - weight loss - purulent sputum

bacterial pneumonia assessment

-recent history of URI -cough -retractions -tachypnea -resp distress -CXR shows consolidation -high fever

major neurotransmitters

..., Acetylcholine - voluntary movement of the muscles. Norepinephrine - wakefulness or arousal. Dopamine - voluntary movement and motivation, "wanting", pleasure, associated with addiction and love.Serotonin - memory, emotions, wakefulness, sleep and temperature regulation. GABA - inhibition of motor neurons. Glycine - spinal reflexes and motor behaviour. Neuromodulators - sensory transmission - especially pain.

Lung abscess results in

...necrosis of the pulmonary tissue and formation of cavities containing necrotic debris or fluid.

TB management

1. Antibiotic therapy - Rifampin, ethambutol, streptomycin, isoniazid, pyrazinamide - Treatment must continue for at least 6 months (usually 9 to 12 months) 2. Infection control - Universal Precautions - Isolation precautions (Airborne), N95 mask, closed negative pressure room - Personal Protective Equipment (PPE) 3. Patient Education - Medication regimen and compliance - Symptom management - Prevention

indication for mechanical ventilation

1. Apnea 2. Cardiac Arrest 3. Respiratory Failure (acute or chronic)

phases of ARDS

1. Injury/exudative phase: 24 hrs after injury. capillary membranes leak fluid that is protein rich, leading to pul. edema. surfactabt cells damaged. alveoli sacs collapse, v/q mismatch, leading to resp. alk. 2. Reparative/ proliferative phase: 14 days after injury. body creates lung tissue to try to heal. but it is very dense/ fibrous leading to decreasd lung compliance and increased hypoxemia 3. Fibrotic phase: 3 wks after injury. by this time some fibrous lung tissue has died. now you have dead lung space. major cause of lung damage

15 yo, c7 (†risk †t6)

1. Which patient below is at MOST risk for developing a condition called autonomic dysreflexia?*

<18 mmHg

10. A patient is experiencing respiratory failure due to pulmonary edema. The physician suspects ARDS but wants to rule out a cardiac cause. A pulmonary artery wedge pressure is obtained. As the nurse you know that what measurement reading obtained indicates that this type of respiratory failure is NOT cardiac related?*

slow hr and severe HTN, less likely lumbar injury

10. Which statements are TRUE about autonomic dysreflexia? Select all that apply:*

anesthetic jelly

11. The nurse is about to assess for bowel impaction in a patient who has developed autonomic dysreflexia. The nurse makes it priority to?* (To avoid increasing autonomic dysreflexia symptoms by increasing the sympathetic reflex due to an irritating stimulus, the nurse should instill an _______ ______ before assessing the rectum for hardened stool. This is also important prior to catheterization to check the bladder for urine.

help open alveoli that collapse

11. You're precepting a nursing student who is assisting you care for a patient on mechanical ventilation with PEEP for treatment of ARDS. The student asks you why the PEEP setting is at 10 mmHg. Your response is:*

(A, B, and E) 3 neg sputum cultures, ss improve, 3 wks tb meds

13. A patient receiving medical treatment for an active tuberculosis infection asks when she can starting going out in public again. You respond that she is no longer contagious when:

vision

17. A patient with active tuberculosis is taking Ethambutol. As the nurse you make it priority to assess the patient's? (can cause inflammation of the optic nerve. vision. If the patient has blurred vision or reports a change in colors, the MD must be notified immediately.)

Vitamin B6

18. A patient taking Isoniazid (INH) should be monitored for what deficiency?*

assess bp (patients who have a SCI at T6 or higher are at MOST risk, a bladder issue is the most common cause of AD)

2. Your patient, who has a spinal cord injury at T3, states they are experiencing a throbbing headache. What is your NEXT nursing action?*

atelectasis (due to decrease in surfactant)

3. During the exudative phase of acute respiratory distress syndrome (ARDS), the patient's lung cells that produce surfactant have become damaged. As the nurse you know this will lead to?*

90 degrees and lower legs

3. You're performing a head-to-toe on a pt w a spinal cord injury at T6. pt is restless, sweaty, and extremely flushed. You assess the BP & HR. BP is 140/98 and hr is 52. You look at the patient's chart and find that their baseline bp is 106/76 and hr is 72. What action should the nurse take FIRST?*

distended bladder, sacral pressure injurt, fecal impaction, UTI

4. You're providing an in-service to a group of new nurse graduates on the causes of autonomic dysreflexia. Select all the most common causes you will discuss during the in-service:* (causes an exaggerated sympathetic reflex responses; most common cause= bladder issues, other common causes= fecal impaction or skin break down including infection)

bladder irritant

5. After taking all the necessary steps for a patient who has developed autonomic dysreflexia, what should the nurse assess FIRST as a possible cause of this condition?*

sildenafil 12 hrs ago

6. The physician orders Nitropaste for a patient who has developed autonomic dysreflexia. Which finding would require the nurse to hold the ordered dose of Nitropaste and notify the physician?*

69yo F, sepsis ( MOST COMMON CAUSE OF ARDS IS SYSTEMIC INFLAMMATION, G-Bact. can cause this)

6. Which patient below is at MOST risk for developing ARDS and has the worst prognosis?*

( B and C) not contagious or ss, + test

6. Your patient is diagnosed with a latent tuberculosis infection. Select all the correct statements that reflect this condition:

headache, sweating, hypertension, slow hr, stuffy nose

7. A patient is receiving treatment for a complete spinal cord injury at T4. As the nurse you know to educate the patient on the signs and symptoms of autonomic dysreflexia What signs and symptoms will you educate the patient about? Select all that apply:*

BO 70/45 (mech vent cause intrathoracic pressure & decrease cardiac output)

8. A patient is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the patient is developing a complication related to their therapy and requires immediate treatment?*

high fowlers with legs lowered

8. What is the BEST position for a patient experiencing autonomic dysreflexia?*

pNeumonia

8th leading cause of death

pale/ cool LE

9. In autonomic dysreflexia, the nurse would expect what finding below the site of the spinal cord injury?* (due to vasconstriction caused by the exaggerated reflex response of the sympathetic nervous system from an irritating stimulus)

pao2 increased

9. You are caring for a patient with acute respiratory distress syndrome. As the nurse you know that prone positioning can be beneficial for some patients with this condition. Which findings below indicate this type of positioning was beneficial for your patient with ARDS?*

ARDS mneumonic symptoms:

A - Acute in onset R - Ratio of PaO2 to FiO2 (P/F ratio) less than 20 regardless of PEEP D - Diffuse bilateral pulmonary infiltrates on CXR S - Swan-Ganz pulmonary artery wedge pressure less than 18 mmHg or no clinical evidence of left atrial hypertension

10 mm ( normally 15 but since pt at high risk, it drops)

A 48-year old homeless man, who is living in a local homeless shelter and is an IV drug user, has arrived to the clinic to have his PPD skin test assessed. What is considered a positive result?

PPD (Mantoux)

A 52-year old female patient is receiving medical treatment for a possible tuberculosis infection. The patient is a U.S. resident but grew-up in a foreign country. She reports that as a child she received the BCG vaccine (bacille Calmette-Guerin vaccine). Which physician's order below would require the nurse to ask the doctor for an order clarification?

airborne, respirator

A 55-year old male patient is admitted with an active tuberculosis infection. The nurse will place the patient in ___________________ precautions and will always wear _____________________ when providing patient care?

Famciclovir (antiviral agents acyclovir, valacyclovir, and famciclovir recommended)

A client at the clinic is diagnosed with genital herpes. Which medication would the nurse anticipate as being ordered for this client? Select all that apply.

halo sign

A client has been admitted for observation after a closed head injury. There is clear fluid leaking from the client's nose. How would the nurse assess if this drainage is CSF?

painless genital ulcer

A client has been admitted with primary syphilis. Which signs or symptoms should the nurse expect to see with this diagnosis?

vomits

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client *should be reported immediately.

daily weights

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? (weight loss will alert the nurse to possible fluid imbalance early in the process.)

Helicopod

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

neutral position (no flexing)

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?

thought content.

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in

Pseudomembranous colitis

A client is in the acute care facility for the administration of intravenous (IV) antibiotics to treat bacterial pneumonia. The client begins to have severe diarrhea 3 days after the IV antibiotics with abdominal cramping and pain. What does the nurse suspect the client has developed due to the antibiotic use?

avoid sedatives/ caffeine 8hr

A client is scheduled for an EEG. The client inquires about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client?

paresthesia

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?

lumbar pucture

A client presents to the emergency department status post-seizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client? *cuz Changes in CSF often occur in many neurologic disorders

raccoon eyes and battle sign

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

s/s ICP

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? (Signs of increased intracranial pressure include headache, blurred vision, vomiting, and lack of energy or sleepiness. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage)

C5

A client with a spinal cord injury has full head and neck control when the injury is at which level?

Absence of reflexes along with flaccid extremities

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

apply stockings prior

A client with tetraplegia has a spinal cord injury (SCI) at C4. He experiences severe orthostatic hypotension with any elevation of his head. Which of the following interventions will the nurse employ to reduce the hypotension? (will improve venous return from the legs. An abdominal binder will also encourage venous return. The nurse should allow time for a slow progression from laying to sitting. Vasopressor drugs may be used to treat the profound vasodilation.)

seal a hole

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following?

severe tbi (traumatic brain injury)

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:

positive romberg, equil

A nurse conducts the Romberg test on a client by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and saves the client from being injured. How should the nurse interpret the client's result?

stick tongue out and move side to side

A nurse is evaluating a client's cranial nerves during a routine examination. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to:

irrigate, remove debris

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?

48-72 hours

A patient has a PPD skin test (Mantoux test). As the nurse you tell the patient to report back to the office in _________ so the results can be interpreted?*

chest x-ray and sputum culture

A patient has a positive PPD skin test that shows an 8 mm induration. As the nurse you know that

ambulate independently

A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require? (Patients with spinal cord injuries from S1 to S5 should be able to ambulate independently, without an assistive device.)

C. white out infiltrates bilaterally

A patient has been hospitalized in the ICU for a near drowning event. The patient's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS?

Muscle spasticity.

A patient is admitted to a specialty care unit with a diagnosis of an upper motor neuron lesion. The nurse assesses the patient and documents the presence of:

Ringing in ears

A patient is taking Streptomycin. Which finding below requires the nurse to notify the physician?*

Propofol (Diprivan)

A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time? (do not affect cerebral blood flow or ICP)

stabilization, early ambulation

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?

brain stem (midbrain, pons, medulla oblongata)

A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe?

sitting up

A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse? (Autonomic dysreflexia, AKA autonomic hyperreflexia, is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in normal people. It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis (most often of the forehead), nausea, nasal congestion, and bradycardia. It occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided (Bader & Littlejohns, 2010). The patient is placed immediately in a sitting position to lower BP)

Normal muscle function

A patient with myasthenia gravis is started on Pyridostigmine. What assessment finding demonstrates the drug is working correctly?*

Brudzinski Sign

A positive sign of meningitis, in which there is an involuntary flexion of the arm, hip, and knee when the patient's neck is passively flexed.

temporal lobe

A region of the cerebral cortex responsible for hearing and language.

occipital lobe

A region of the cerebral cortex that processes visual information

acute tracheobronchitis

Acute inflammation of the mucous membranes of the trachea and bronchial tree.; usually after a viral infection patho: mucopurulent sputum

eval corneal reflexes (to rapidly assess brain stem function)

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:

epidural hematoma signs

Altered LOC, dilated and sluggish non reactive pupil on the side of herniation, hemiparesis or hemiplegia on opposite side of injury.

Syphilis

An instructor is teaching a group of students about the incidence of sexually transmitted infections (STIs) and those that must be reported by law. The instructor determines that the students have understood the information when they state that which STI must be reported?

dermatome

Area of skin supplied by a single spinal nerve

sepsis, blood trans, pancreatitis

As the nurse you know that acute respiratory distress syndrome (ARDS) can be caused by direct or indirect lung injury. Select below all the INDIRECT causes of ARDS

Noncompliance

As the nurse you know that one of the reasons for an increase in multi-drug-resistant tuberculosis is

aspiration complications

Aspiration pneumonia: broncho or lobar Inflammation—gas diffusion is impaired. Respiratory distress syndrome May develop if inflammation is widespread Pulmonary abscess May develop if microbes are in aspirate Systemic effects When aspirated materials (solvents) are absorbed into blood

Promoting effective airway clearance

Assess lung sounds at least every 2-4 hours. Measures to clear airway: suctioning, CPT, position changes, promote mobility Humidification Medications

bradycardia, hypertension, bradypnea- cushing's triad

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.

t6

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

Transcranial Doppler

Blood flow speed in brain vessels measured Nsg: -tell patient that a hand machine is placed over neck and eyes

aspiration

Breathing fluid, food, vomitus, or an object into the lungs. this leads to inflammatory reactions, hypoventilation, and ventilation-perfusion mismatch. risk factors = LOC

battle sign

Bruising behind an ear over the mastoid process that may indicate a skull fracture.

pleural effusion causes

CHF pneumonia pulmonary embolism

trigeminal neuralgia management

Carbamazepine

neurogenic shock

Circulatory failure caused by paralysis of the nerves that control the size of the blood vessels, leading to widespread dilation; seen in patients with spinal cord injuries.

Community Acquired Pneumonia (CAP)

Community setting or within first 48 hours post hospitalization oRate of infection increases with age oS. Pneumoniae is the most common cause among adults oViral origin in infants and children

Infection

Contamination or invasion of body tissue by pathogenic organisms host interaction with an organism

CN 7 (facial nerve)

Controls muscles of facial expression Taste sensations from the anterior 2/3 of the tongue. discriminate between the tastes of sugar and salt. Motor and sensory The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve?

pneumonia s/s

Coughing, CRACKLES, sputum production, pleuritic chest pain, shaking, chills, fever, dyspnea, tachypnea, malaise, decreased breath sounds

Broca's area/ speech

Critical for motor control of speech lies in the LEFT inferior frontal lobe A patient has been diagnosed with damage to Broca's area of the left frontal lobe. To document the extent of damage, the nurse would assess the patient's:

edema, ischemia, infection, seizures, hyperthermia

Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following arecauses of secondary brain injury? Select all that apply.

Diffuse Axonal Injury (DAI)

Diffuse brain injury that is caused by stretching, shearing, or tearing of nerve fibers with subsequent axonal damage. idespread axon damage in the brain seen with head trauma. Patient develops immediate coma

MS (multiple sclerosis)

Disease of the CNS - immune system attacks the protective myelin sheath that covers nerve fibers. sclerosis=hardening

Sildenafil (Viagra)

Do NOT mix with NITRATES (nitroglycerine, isosorbide dinitrate) and some ALPHA-blockers. Erection greater than 4 HOURS—REFER to ED Tadalafil (Cialis) Do NOT give within 3 to 6 MONTHS of an MI, stroke Contraindicated with nitrates Agent for Erectile Dysfunction

resp irregular, slow bounding pulse, widened pulse pressure

Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate? Select all that apply.

covid s/s

Fatigue, myalgia, congestion, sore throat, diarrhea, anosmia (smell), and ageusia (taste) tx w rest, hydrate, antipyretic agents increased risk for pneumonia, venous thromboembolism. can lead to shock/ resp failure

TBI temp

Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia.

lung consolidation

Firming of the lungs as a result of fluid accumulation.

chest trauma

First emergency approach to all chest injuries is ABC (airway, breathing, circulation) followed by rapid assessment & treatment of life-threatening conditions.

hypoxemia, worse neuro deficit

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

mri safety

For patient safety, the nurse prevents any patient care equipment containing metal or metal parts (e.g., portable oxygen tanks, wheelchairs) from entering the room where the MRI is located. The nurse also assesses for and removes any medication patches with foil backing (such as nicotine patches) that may cause a burn while an MRI scan is being performed.

types of aphasia

Global (Speech is absent or severely reduced), Broca's (Person can understand language, but cannot use language themselves), Wernicke's (Can speak, but cannot understand)

tuberculosis; tubercles

Granulomas and Ghon tubercule

lung cancer s/s

Hemoptysis, dyspnea (may be confused with TB, but TB has night sweat), hoarseness, cough, change in endurance, chest pain, pleuritic pain on inspiration, displaced trachea. May metastasize to bone Dyspnea, fatigue, nausea and vomiting, anorexia

ICOUGH

I - Incentive Spirometry. C - Coughing & deep breathing. O - Oral care (brush teeth and use mouthwash 2x a day). U - Understanding (pt and staff education). G - Getting out of bed at least 3x a day. H - HOB elevation. TX to Prevent atelectasis

Decreased/ flaccid muscle tone

If a client has a lower motor neuron lesion, the nurse would expect to observe which manifestation upon physical assessment?

Brain stem and sacral

In the parasympathetic nervous system the ganglia are found? Select all that apply:* A. Cervical B. Brain stem C. Lumbar D. Sacral

Thoracic and lumbar

In the sympathetic nervous system ganglia are found? Select all that apply:* A. Thoracic B. Brain stem C. Sacral D. Lumbar

pneumonia

Inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi, and viruses

Pleurodesis

Infusion of a sterile, irritating substance into the pleural space, causing the pleural linings to fuse to one another by developing scar tissue lungs become stuck to chest walls

ARDS medical management

Intubation, mechanical ventilation with PEEP (high 10-20 pressure) to keep alveoli open Hypovolemia Prone positioning is best for oxygenation, frequent repositioning to safeguard integumentary Nutritional support, enteral feedings preferred Reduce anxiety

trigeminal neuralgia interventions

Keep room free from drafts; moderate temperature; avoid touching face; no washing/shaving affected area. Provide lukewarm water and cloths. Warm mouthwash, soft bristle toothbrush. Avoid hot/cold liquids. Puree food, serve lukewarm.

ARDS patho

Lung injury leads to respiratory distress within 24-48 hours Severe acute inflammation and pulmonary edema without evidence of fluid overload or impaired cardiac function Mortality rate 30%-40% from multi-system organ failure in those untreated fluid fills alveoli so gas exchange cant occur. the alveolar sac collapses and leads to hypoxemia, organs suffer from low co2

TB diagnostics

Mantoux test, Acid fast bascillus in sputum culture, chest x-ray, rapid sputum, NAAT. sputum cultures early in morning for 3 consecutive days

true

Meningitis is an inflammation of the pia mater, the arachnoid, and the cerebrospinal fluid-filled subarachnoid space. T/F

covid increase of thromboembolism

Most patients are prescribed anticoagulant agents as prophylaxis, as they have a higher risk of venous thromboembolism (VTE)

FALSE (CNS, not PNS)

Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the peripheral nervous system. T/F

dry suction control

No water Dial in desired negative pressure Must vent when decreasing pressure

geri TBI

Nursing interventions with older adults who have had a TBI should focus on balance, coordination, as well as energy conservation measures to minimize fatigue and other measures to reduce environmental noises.

Health care associated pneumonia

Often caused by multidrug‐resistant organisms oEarly diagnosis and treatment are critical

Syphilis

Painless chancres are associated with which systemic disease?

bell's palsy management

Prednisone 60mg divided in 4-5 doses daily and tapered of 7-10 days Acyclovir (when caused by Zoster) Lubricating eye drops and patch at night if unable to close

lung abscess s/s

Purulent, foul-smelling/tasting sputum fever chills dyspnea cough weight loss pleural friction rub vary from a mild productive cough to acute illness, productive cough with foul sputum, leukocytosis, pleurisy, dyspnea, weakness, anorexia, and weight loss

TB drugs

RIPE rifampin, isoniazid, pyrazinamide, ethambutol

2 types of pneumococcal vaccines

Recommended for all adults 65 years of age or older and 19 years or older with conditions that weaken the immune system

ARDS s/s

Refactory hypoxemia, decrease pulmonary compliance (elasticity); dyspnea, noncardiac-associated bilateral pulmonary edema; dense pulmonary infiltrates on x-ray (ground-glass appearance

hypothalamus

Responsible for regulating basic biological needs: hunger, thirst, temperature control

Autonomic Dysreflexia/Hyperreflexia

S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST!

ARDS causes

SPARTAS - capillary permiability increses S= sepsis P=pneumonia, Pancreatitis A= Aspiration R= uRemia T=Trauma, Toxic chemicals inhalation A= Amnionic fluid emboli S= Shock *also think about increase Conc of O2, Heroine overdose

Bradycardia, bronchoconstriction, constricted pupils, bladder contraction

Select all the signs and symptoms a patient can experience when the stimulation of the parasympathetic nervous system: Select all that apply:*

Tachycardia, hyperglycemia, dilated pupils, bronchodilation, sweating

Select all the signs and symptoms a patient can experience with the stimulation of the sympathetic nervous system: Select all that apply:

atropine, ipratropium

Select the drugs below that are considered anticholinergic drugs (also called parasympatholytic):* A. Pyridostigmine B. Atropine C. Ipratropium D. Propranolol

Albuterol Dopamine Epinephrine

Select the drugs below that are considered sympathomimetic drugs:* A. Albuterol B. Dopamine C. Epinephrine D. Propranolol

Myasthenic Crisis

Severe muscle weakening, leading to respiratory distress an acute exacerbation of myasthenia gravis triggered by infection, surgery, emotional distress, or overdose or inadequate medication.

pneumonia manifestations

Sudden onset of fever Chills Cough Sputum production Fatigue Loss of appetite Dyspnea Tachypnea Tachycardia Pleuritic pain Crackles in lungs

lumbar puncture post op

Supine 4 to 12 hours *monitor vital signs and neurological signs that may indicate leakage of CSF *position the client flat as prescribed *encourage fluids to replace CSF obtained from the specimen collection or from leakage *monitor i & o

12 days of cranial nerves

TWELVE TONGUES PROTRUDIN' - ELEVEN NECK MUSCLES MOVIN' - TEN, GUTS A-FLOWIN' - NINE, THROATS SWALL-OW-IN' - EIGHT, EARS A-HEARIN' - SEVEN, FACES SNEERIN' - SIX, EYES SIDE-PEERIN' - FIVE FEELS AND STINGS! (TIC DOULOUREUX) - FOUR, DOWN AND OUT, - THREE MOVES EYES ABOUT, • TWO LETS YOU SEE, - AND SMELL WITH NERVE NUMBER ONE, IT'S OLFAÇT'RY!

Noninvasive positive pressure ventilation

Technique uses positive pressure to keep alveoli open and improve gas exchange without airway intubation

moving towards chest

The Family Nurse Practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

Pns, x

The _________ nervous system stimulates cranial nerve ______, which is responsible for slowing the heart rate, constricting the airway, and stimulating digestion

CSF cloudy

The nurse assists the health care provider (HCP) in completing a lumbar puncture (LP). Which should the nurse note as a concern? normally clear and colorless. cloudy= Increased protein, lipids, or infection (CSF) normal BP= 80-100

no food/ drink

The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to (Significant findings of CN IX (glossopharyngeal) include difficulty swallowing (dysphagia) and impaired taste, and significant findings of CN X (vagus) include weak or absent gag reflex, difficulty swallowing, aspiration, hoarseness, and slurred speech (dysarthria)

Cerebral Perfusion Pressure (CPP) 50-70

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?

powder under liner

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?

Impaired skin integrity

The nurse is caring for a client with genital herpes experiencing a reoccurrence. Which nursing diagnosis would be the priority?

temp increase

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?

burr hole

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? (considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.)

bruising of mastoid

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency department. The medic reports that a client is unconscious with edema of the head and face and Battle sign. What clinical picture would the nurse anticipate?

Childhood immunizations

The nurse is giving an educational talk to a local parent-teacher association. A parent asks how to help the family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections?

cn 10 (vagus)

The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves? (has to do with the gag reflex, laryngeal hoarseness, swallowing ability, and the symmetrical rise of the uvula and soft palate)

CN 1 (olfactory)

The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve?

C section

The nurse is working in the labor and delivery suite when a client with active herpes simplex virus type 2 (HSV-2) appears in active labor. Which adjustment in the plan of care will the nurse prepare for?

CN 2 (optic nerve)

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?

initial damage to brain

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury? (The primary injury results from the initial damage from the traumatic event. The secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually due to cerebral edema and increased intracranial pressure.)

3 different sputum specimens on 3 different days

The physician orders an acid-fast bacilli sputum culture smear on a patient with possible tuberculosis. How will you collect this?

Cerebral angiography (arteriography)

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?

Acetylcholine (ACh)

The postganglionic neuron releases what neurotransmitter in the parasympathetic nervous system?* A. Arginine B. Norepinephrine C. Dopamine D. Acetylcholine

CN 8 (Vestibulocochlear/ acoustic)

The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve?

Norepinephrine (NE)

The sympathetic nervous system postganglionic neuron releases what neurotransmitter?* A. Acetylcholine B. Norepinephrine C. Both Acetylcholine and Norepinephrine D. Arginine

Acetylcholine (ACh)

The sympathetic nervous system preganglionic neuron releases what neurotransmitter?* A. Serotonin B. Acetylcholine C. Norepinephrine D. Arginine

gag reflex

To assess a client's cranial nerve function, a nurse should assess:

memory problems

To help assess a client's cerebral function, a nurse should ask:

Types of Chest Drainage systems

Traditional Water Seal Dry Suction Water Seal Dry Suction

False (has 2 neurons)

True or False: The autonomic nervous system is unique because it has only one neuron that synapses in an autonomic ganglion. Hence it has only pregangolic neurons not postganglionic neurons.*

False (multi-organ)

True or False: Tuberculosis is a contagious bacterial infection caused by mycobacterium tuberculosis and it only affects the lungs

positive end-expiratory pressure (PEEP)

Use of a mechanical ventilator to increase the volume of gas in the lungs at the end of exhalation, thus improving gas exchange -airway pressure is maintained above atmospheric pressure

Imiquimod

Used to treat external genital warts

Azithromycin

Used to treat the clap (chlamydia)

mechanical ventilation

Using a machine to move air into and out of the lungs Positive or negative pressure device to maintain ventilation and oxygenation for a prolonged period

basilar skull fracture

Usually occurs following diffuse impact to the head (such as in falls, motor vehicle crashes); generally results from extension of a linear fracture to the base of the skull and can be difficult to diagnose with a radiograph (x-ray). Raccoon eyes (periorbital ecchymosis) and Battle's sign (mastoid ecchymosis).

Bradycardia, bronchoconstriction

What are some side effects of adrenergic antagonist drugs (sympatholytic): select all that apply* A. Tachycardia B. Bradycardia C. Bronchoconstriction D. Bronchodilation

strep pneumonia

What is the most common cause of community acquired pneumonia (CAP)? Sudden onset of chills, fever, pleuritic chest pain, tachypnea, and respiratory distress

cerebellum

What part of the brain controls and coordinates muscle movement? A patient recently noted difficulty maintaining his balance and controlling fine movements. The nurse explains that the provider will order diagnostic studies for the part of his brain known as the:

No metals in room

What safety actions does the nurse need to take for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)?

Decerebrate

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

young, alcohol, drugs, male

Which are risk factors for spinal cord injury (SCI)? Select all that apply.

fRontal

Which cerebral lobes is the largest and controls abstract thought? also controls information storage or memory and motor function.

Subdural Hematoma (SDH)

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

Dilated pupils

Which is a sympathetic effect of the nervous system?

Colonization

Which of the following describes microorganisms present without host interference or interaction?

chorea

Which of the following terms is used to describe rapid, jerky, involuntary, purposeless movements of the extremities?

absent brainstem reflexes, apnea, coma

Which signs are considered cardinal signs of brain death? Select all that apply.

Aerobic bacteria, smears bright red

Which statement is correct regarding mycobacterium tuberculosis?

blanket

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury?

Electromyography (EMG)

Which term refers to a method of recording, in graphic form, the electrical activity of a muscle?

ataxia

Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking? the inability to coordinate voluntary muscle action; tremors (rhythmic, involuntary movements) noted at rest or during movement suggest a problem in the anatomic areas responsible for balance and coordination.

epidural

Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)?

Autonomic dysreflexia

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

autonomic dysreflexia

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

(C, D, E, and F) Long-term care resident , Inmate , IV drug user, HIV

You are assessing your newly admitted patients who are all presenting with atypical signs and symptoms of a possible lung infection. The physician suspects tuberculosis. So, therefore, the patients are being monitored and tested for the disease. Select all the risk factors below that increases a patient's risk for developing tuberculosis

Rifampin

You note your patient's sweat and urine is orange. You reassure the patient and educate him that which medication below is causing this finding?

pao2 45 (refractory hypoxemia)

You're providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS)?

a. pao2 40 (resp. alkalosis)

You're providing care to a patient who was just transferred to your unit for the treatment of ARDS. The patient is in the exudative phase. The patient is ordered arterial blood gases. The results are back. Which results are expected during this early phase of acute respiratory distress syndrome that correlates with this diagnosis?

fluid in alveoli

You're teaching a class on critical care concepts to a group of new nurses. You're discussing the topic of acute respiratory distress syndrome (ARDS). At the beginning of the lecture, you assess the new nurses understanding about this condition. Which statement by a new nurse demonstrates he understands the condition?

(B, D, E, F- cough 3wks) night sweats, Hemoptysis, Chills, Fever

You're teaching a group of long-term care health givers about the signs and symptoms of tuberculosis. What signs and symptoms will you include in your education

No special PPE is needed

Your patient with a diagnosis of latent tuberculosis infection needs a bronchoscopy. During transport to endoscopy, the patient will need to wear?

Uric acid

Your patient, who is receiving Pyrazinamide, report stiffness and extreme pain in the right big toe. The site is extremely red, swollen, and warm. You notify the physician and as the nurse you anticipated the doctor will order?

Halo sign

a blood stain surrounded by a yellowish stain; highly suggestive of a cerebrospinal fluid leak

epidural hematoma

a collection of blood in the space between the skull and dura mater

electromyography

a diagnostic test that measures the electrical activity within muscle fibers in response to nerve stimulation obtained by inserting needle electrodes into the skeletal muscles to measure changes in the electrical potential of the muscles

epidural hematoma (EDH)

a mass of blood that forms between the skull and the dura mater as a result of the brain colliding against the skull, such as from a head injury or a fall

susceptible host

a person likely to get an infection or disease one that does not possess immunity to a particular pathogen

lung abscess

a pus-containing lesion of the lung parenchyma that results in a cavity formed by necrosis of lung tissue. MOST COMMON COMPLICATION OF BACTERIAL PNEUMONIA Can lead to empyema, bronchopleural fistula

Glasgow Coma Scale (GCS)

a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints

Concussion

a temporary loss of neurologic function with no apparent structural damage to the brain. Contusion is a bruising of the brain surface. no apparent structural damage

tuberculin skin test (mantoux skin test)

a test to determine past or present tuberculosis infection

anosmia

absence of the sense of smell

Closed TBI (blunt trauma):

acceleration/deceleration injury occurs when the head accelerates and then rapidly decelerates, damaging brain tissue no penetration through skull ex.: concussion, contusion, hematoma, injury to extracranial blood vessels, hypoxia, drug overdose, near drowning, acceleration/deceleration

empyema

accumulation of pus in the pleural cavity w/ drainage, fluid will contain pus, have low pH (acidic), low glucose, & high LDH

chronic atelectasis s/s

acute+ - pulm infection

myesthenia gravis

an autoimmune disorder affecting the myoneural junction and is characterized by varying degrees of weakness of the voluntary muscles. Guillain-Barré syndrome is an autoimmune attack on the peripheral nerve myelin.

gullaine barre syndrome

an inflammation of the myelin sheath of peripheral nerves, characterized by rapidly worsening muscle weakness that may lead to temporary paralysis; also known as infectious polyneuritis

pleurisy

an inflammation of the pleura that produces sharp chest pain with each breath *can be heard with stethoscope.

Reservoir

any person, plant, animal, substance, or location that provides nourishment for microorganisms and enables further dispersal of the organisms

frontal lobe

associated with reasoning, planning, parts of speech, movement, emotions, and problem solving

ms assessment

ataxia weakness spasticity vertigo, tinnitus nystagmus, patchy blindness chewing and swallowing difficulties scanning speech paresthesias incontinence/retention of urine, constipation emotional lability sexual impairment

myasthemia gravis (MG)

autoimmune neuromuscular disorder characterized by weakness of voluntary muscles

neuron

basic unit of the nervous system

TB sputum culture

best done early in the morning and ALWAYS before eating. done 3 consecutive days d/c tx after 3 negative cultures on 3 diff days.

Intracerebral Hemorrhage

bleeding into the brain as a result of a ruptured blood vessel within the brain

atelectasis management

bronchodilators antibiotics mucolytic agents bronchoscope can be used to remove a thick, tenacious secretion or a mucous plug ventilation management with intubation incentive spirometry 10x every hour cough, deep breathing, changing positions and early ambulation

brain contusion

bruising of the surface of the brain without penetration characterized by loss of consciousness associated with stupor and confusion Longer period of unconsciousness with more symptoms of neurologic deficits and changes in vital signs

function of CSF

buoyancy, protection, chemical stability It cushions the brain and spinal cord.

Inadvertent removal of an endotracheal tube

can cause laryngeal swelling, hypoxemia, bradycardia, hypotension, and even death. Measures must be taken to prevent premature or inadvertent removal.

upper motor neuron lesions

cause hyperactive reflexes, no muscle atrophy, and muscle spasticity.

Asbestosis

caused by asbestos particles in the lungs and usually occurs after working with asbestos

Septic meningitis

caused by bacteria ONLY, associated with high mortality and severity -> etiology is AGE dependent caused by bacteria (Streptococcus pneumoniae, Neisseria meningitidis)

aseptic meningitis

caused by viral infection secondary to cancer or a weak immune system

trigeminal neuralgia

characterized by severe lightning-like pain due to an inflammation of the fifth cranial nerve

neurotransmitters

chemical messengers that cross the synaptic gaps between neurons

TBI increased risk

children 0 to 4 years old, adolescents ages 15 to 19 years, and adults 65 years and older; higher in males

Sarcoidosis

chronic inflammatory disease in which small nodules (granulomas) develop in lungs, lymph nodes, and other organs Occurs between 20 and 40 years of age ❖More common in African American women autoimmune disease

TB risk factors

close contact with someone who has active TB, immunocompromised status, IV drug user, person who lives in institutions, lower socioeconomic group, incidence increasing in immigrant populations, poverty areas, elderly, alcoholics, drug abusers, and people with AIDS

atelectasis

collapsed lung; incomplete expansion of alveoli usually caused by increased fluids often seen post op due to decreased ambulation & deep breathing

Mantoux skin test

common for testing of previous exposure or current infection with mycobacterium tuberculosis

brain damage primary injury

consequence of direct contact to head/brain during the instant of initial injury oContusions, lacerations, external hematomas, skull fractures, subdural hematomas, concussion, diffuse axonal

hemoptysis

coughing up blood

Brain Damage: Secondary Injury

damage evolves over ensuing days and hours after the initial injury oCaused by cerebral edema, ischemia, or chemical changes associated with the trauma

spinal cord injury (SCI)

damage to spinal cord as result of trauma; spinal cord can be bruised or completely severed ❖Males account for 78% of SCIs ❖Average age of injury is 43 ❖Risk factors include young age, male gender, alcohol and drug use ❖Major causes of death are pneumonia, pulmonary embolism (PE), and sepsis

continuous positive airway pressure (CPAP)

device used to treat sleep apnea; includes a mask that fits over the sleeper's nose and mouth, which is connected to a pump that pumps air into the person's airways, forcing them to remain open

pulmonary tuberculosis (TB)

disease caused by the presence of Mycobacterium tuberculosis in the lungs; characterized by the formation of tubercles, inflammation, and necrotizing caseous lesions (caseous necrosis). Spreads by airborne transmission through droplets then moves to other parts of the body such as the kidneys, bones, and cerebral cortex.

silicosis

disease due to silica or glass dust in the lungs; occurs in mining occupations

sarcoidosis s/s

dyspnea, cough, hemoptysis, congestion, anorexia, fatigue, and weight loss

Electroencephalography (EEG)

electrodes applied on the scalp or through microelectrodes placed within the brain tissue. It provides an assessment of cerebral electrical activity. It is useful for diagnosing and evaluating seizure disorders, coma, or organic brain syndrome. Tumors, brain abscesses, blood clots, and infection may cause abnormal patterns in electrical activity. The EEG is also used in making a determination of brain death.

basilar skull fracture

fracture at the base of the skull

CN 3 (oculomotor)

has to do with pupillary response, conjugate movements, and nystagmus.

BCG vaccine for TB

helps prevent, not widely used in US, given to high risk individuals, can cause a false positive skin test

refractory hypoxemia

hypoxemia that does not respond to O2 therapy HUGE INDICATOR OF ARDS

acute respiratory failure

inability of the lungs to perform their ventilatory function.

kernig sign

inability to fully extend the knees with hips flexed.

ageusia

inability to taste

atelectasis prevention

incentive spirometer 10x/ hr - assess tidal vol - freq turning, early mobilization, incentive spirometer, pressurized metered dose inhaler

Meningitis s/s

include headache, fever, changes in LOC, behavioral changes, nuchal rigidity (stiff neck), positive Kernig sign, positive Brudzinski sign, and photophobia

endotracheal intubation (ET)

inserting tube through mouth and into trachea; creates open upper respiratory airway Maintain cuff pressure between 20 and 25 mm Hg intubation for no longer than 14 to 21 days (after will require a tracheostomy)

silent aspiration

lack of cough when food or liquid enters the airway

lung abscess management

listen to lungs absent decreased and pleural friction rub or crackles chest c ray with infiltrate antibiotics iv 3weeks + then if needed 4-12 weeks more and drainage high protein and calorie diet deep breathe and coughing every 2 hours and supportive care and education

temporal lobe

located inferior to the frontal and parietal lobes, this lobe contains the auditory receptive areas and plays a role in memory of sound and understanding of language and music.

occipital lobe

located posterior to the parietal lobe, this lobe is responsible for visual interpretation and memory

Upper Motor Neuron Lesions

loss of muscle function as a consequence of strokes damaging neurons in the brain

Lower Motor Neuron Lesions

loss of voluntary control, decreased muscle tone, flaccid muscle paralysis, muscle atrophy, absent or decreased reflexes

PET scan

method of brain imaging using positron emissions The patient either inhales a radioactive gas or is injected with a radioactive substance that emits positively charged particles. When these positrons combine with negatively charged electrons (normally found in the body's cells), the resultant gamma rays can be detected by a scanning device that produces a series of two-dimensional views at various levels of the brain. permits the measurement of blood flow, tissue composition, and brain metabolism and thus indirectly evaluates brain function.

Spinal Cord Injury assessment

monitor resp, lung sounds/cough, monitor motor/sensory function, assess for spinal shock, monitor bladder retention/distention, temperature

guillain barre syndrome assessment

motor losses symmetrical, usually beginning in lower extremities, then extend upward to include trunk, upper extremities, cranial nerves, and vasomotor funciton; deep tendon reflexes disappear.

Comatose

nurse is giving report on a pt. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the on-coming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? (A normal response is 15. A score of 7 or less is considered comatose.)

ms nursing interventions

o Promote motor function → muscle stretching, frequent rest periods, avoid sudden position changes o Minimize fatigue → brief rest periods in day; avoid overhearing, overexertion o Optimize sensory function → eye patch for double vision, orientation to environment, remove obstacles o Maintain urine elimination → adequate intake, voiding schedule o Normalize family process o Promote sexual functioning

items in chest drainage systems

oA suction source oA collection chamber for pleural drainage oAnd a mechanism to prevent air from reentering the chest with inhalation Used in removal of air and fluid from the pleural space and re-expansion of the lungs

open tbi (penetrating)

object penetrates the brain or trauma is so severe that the scalp and skull are opened direct penetration thru skull to brain ex.: gunshot wound, knife/sharp object penetration, skull fragments, direct trauma

bell's palsy

paralysis of the facial nerve, causing muscular weakness in one side of the face.

Tachycardia, hypertension

patient is started on a norepinephrine drip. What side effects can this medication cause? Select all that apply:* A. Tachycardia B. Hypoglycemia C. Hypertension D. Bronchoconstriction

Frontal lobe

patient sustained a head injury during a fall and has changes in personality and affect. What part of the brain does the nurse recognize has been affected in this injury?

spinal shock

physiologic response that occurs between 30 and 60 minutes after trauma to the spinal cord and can last up to several weeks. spinal shock presents with total flaccid paralysis and loss of all reflexes below the level of injury.

lung abscess diagnostics

pleural friction rub crackles chest x ray sputum cultures bronchoscopy ct of chest

complications of mechanical ventilation

pneumothorax, ulcers

parietal lobe

portion of the cerebral cortex lying at the top of the head and toward the rear; receives sensory input for touch and body position

Decerebrate posturing

posturing in which the neck is extended with jaw clenched; arms are pronated, extended, and close to the sides; legs are extended straight out; more ominous sign of brain stem damage. Most Severe. described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing.

diaphoresis

profuse sweating

parietal lobe

receives sensory input for touch and body position

electroencephalogram

record of the electricity in the brain

coal worker's pneumoconiosis (CWP)

respiratory disease caused by chronic or repetitive inhalation of coal dust; often called black lung or anthracosis

ARDS (acute respiratory distress syndrome)

respiratory insufficiency marked by progressive hypoxia Characterized by sudden, progressive pulmonary edema, increasing bilateral lung infiltrates visible on chest x-ray, and absence of an elevated left atrial pressure

Hospital Acquired Pneumonia (HAP)

s/s include pleural effusion, HIGH fever, & tachycardia

propofol diprivan

sedative of choice for ICP *do not affect cerebral blood flow or ICP ultra-short acting, rapid onset drug with elimination half-life of less than an hour titratable to its desired clinical effect but still provides the opportunity for an accurate neurologic assessment

CN 8 Vestibulocochlear

sensory, hearing and balance

cholinergic crisis

severe muscle weakness and respiratory paralysis due to excessive acetylcholine; often seen in patients with myasthenia gravis as an adverse effect of drugs used to treat the disorder

pons

sleep and arousal HELPS REGULATE RESPIRATIONS

Cranial Nerve Mnemonics 02 (Sensory, Motor or Both)

some say marry money but my brother says big brains matter most

SCI

spinal cord injury

pneumonia labs

sputum culture WBCs chest x-ray

Infectious disease

state in which the infected host displays a decline in wellness due to the infection

tracheotomy

surgical operation of cutting into the trachea (windpipe)

Thymectomy

surgical removal of the thymus gland

s/s acute atelectasis

tachycardia, tachypnea, pleural pain, central cyanosis

Medulla

the base of the brainstem; controls heartbeat and breathing Reflex centers for respiration, blood pressure, heart rate, coughing, vomiting, swallowing, and sneezing

agnosia

the loss of ability to recognize objects through a particular sensory system

intracranial bleeding

this is the most common cause of death of hemophilia

N. meningitidis

transmitted by secretions or aerosol contamination, and infection is most likely in dense community groups such as college campuses

2 types of pleural effusion

transudate and exudate

echoencephalography (EchoEG)

ultrasound technology is used to record brain structures in the search for abnormalities

ceftriaxone

used to treat gonorrhea

nitropaste

vasodilator Topical ointment dosed by the inch Used for chronic angina//HTN Lasts 3-6 hours

COncussion

violent shaking up or jarring of the brain

cerebral angiography

x-ray imaging of the arterial blood vessels in the brain after injection of contrast material

myelography

x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. The water-based contrast agent disperses upward through the CSF to outline the spinal subarachnoid space and shows any distortion of the spinal cord or spinal dural sac caused by tumors, cysts, herniated vertebral discs, or other lesions.

pneumonia sputum

yellow-green

atelectasis assessment

• Characterized by increased work of breathing and hypoxemia ❖Decreased breath sounds and crackles over the affected area ❖Chest x-ray • spo2 & HBG low

spinal cord injury collaborative problems

❖DVT ❖Orthostatic hypotension ❖Autonomic dysreflexia

pleural effusion

❖Fluid collection in pleural space usually secondary to heart failure, TB, pneumonia, pulmonary infections *usually found on accident

infectious neuro disorders

❖Meningitis ❖Brain abscesses ❖Various types of encephalitis ❖Creutzfeldt-Jakob disease (CJD) ❖Variant Creutzfeldt-Jakob disease (vCJD)

Autoimmune Nervous System DisordersAutoimmune Nervous System Disorders

❖Multiple sclerosis (MS) ❖Myasthenia gravis ❖Guillain-Barré syndrome