NU 3301 Exam 4

SHORT ANSWER ON EXAM: What are the s/s to educate pt going home with concussion & what action should they take?

If patient loses consciousness must be seen in ER- CT scan Instruct patents to report any N&V Confusion, worsening ha, vision changes, dizziness, drainage from eyes or nose or seizures -call 911 NOTE: keep pt awake, provide low stimulation environment (dim lighting, quiet)

Nursing interventions for renal calculi

Maintain fluid intake (IV and po combined) of 200 mL/hour while awake, run IV at 125-150 mL/hour during night. Administer IVPB antibiotics. Strain urine, save stones for analysis Keep track of urine output, characteristics, report promptly if it drops Emotional support Educate on diet, fluid needs, prevention of UTI Teach s/s of UTI, report promptly Going home: finish ALL of prescribed antibiotics

Temporal lobe seizures - focal seizures

Most seizures last from 30 seconds to 2 minutes Medical emergency- if seizures last longer than 5 minutes or if a patient has many seizures and does not wake up between them. Temporal lobe seizures begin in the temporal lobes of the brain, which process emotions and are important for short-term memory. Some symptoms of a temporal lobe seizure may be related to these functions, including having odd feelings — such as euphoria, deja vu or fear. Temporal lobe seizures AKA focal seizures with impaired awareness. Some people remain conscious, but during more-intense seizures, patients might look awake but be unresponsive. Their lips and hands may make purposeless, repetitive movements. Temporal lobe seizures may stem from an anatomical defect or scar in the temporal lobe, but the cause is often unknown. Temporal lobe seizures are treated with medication. For some people who don't respond to medication, surgery may be an option.

Etiology of GTCS

*Injury or infection* -Traumatic head injuries -Infections, such as encephalitis or meningitis, or a history of such infections -Injury due to a previous lack of oxygen -Stroke *Congenital or developmental abnormalities* -Blood vessel malformations in the brain -Genetic syndromes -Brain tumors *Metabolic disturbances* -Very low blood levels of glucose, sodium, calcium or magnesium *Withdrawal syndromes* -Using or withdrawing from drugs, including alcohol and benzodiazapines

Epidural hematoma

-Rapid bleeding often from tearing of menigeal artery causes a collection of blood (hematoma) that presses on the brain, causing a rapid increase of the pressure inside the head (intracranial pressure). This pressure may result in additional brain injury. -Medial emergency - permanent brain damage and death if left untreated After the injury there may be a period of lucidity followed by rapid deterioration and death. Monitor pt q 5- 10 minutes call rapid response if changes occur. -Headache, N&V, Increased ICP, fixed and dilated pupil -To OR stat

Nurse teaching for pts being cared for at home with pyelonephritis.

-continue course of antibiotic therapy even after sx resolve to ensure bacteria have been eliminated and to prevent recurrence of infection and antibiotic resistance -drink 3L of fluids per day unless contraindicated -monitor urinary output and report if urine volume is < fluid intake -monitor daily wt and report sudden increases

Glasgow Coma Scale (pp 928, Porth, Table 37-3) [higher # = better the pt] [lowest score = 3]

*Eye Opening (E)* (4) spontaneous (3) to call (2) to pain (1) none *Motor Response (M)* (6) obeys commands (5) localized pain (4) normal flexion (withdrawal) (3) abnml flexion (decorticate) (2) extension (Decerebrate) (1) None (flaccid) *Verbal Response (V)* (5) Oriented (4) Confused conversation (3) Inappropriate words (2) Incomprehensible sounds (1) None GCS Score = E + M + V Best possible score : 15 Worse possible score: 3

Status epilepticus (SE)

*Status epilepticus* (SE) is a single *epileptic seizure* lasting more than five minutes or two or more *seizures* within a five-minute period without the person returning to normal between them. **Medical Emergency- that may lead to brain damage or death** The benzodiazepines are some of the most effective drugs in the treatment of acute seizures and status epilepticus. The benzodiazepines most commonly used to treat status epilepticus are: diazepam (Valium) lorazepam (Ativan)and midazolam(Versed)

Generalized: Tonic-Clonic Seizure

- *Causes a loss of consciousness and violent muscle contractions.* -Generalized tonic-clonic seizure — is caused by abnormal electrical activity throughout the brain. Sometimes, this type of seizure can be triggered by epilepsy or extremely low blood sugar, a high fever or a stroke. -Many people who have a Generalized Tonic/Clonic Seizure never have another one and don't need treatment. -Recurrent seizures may need treatment with daily anti-seizure medications to control and prevent future seizures.

Complications of Frontal Lobe Seizures

-*Status Epilepticus* Frontal lobe seizures tend to occur in clusters and may provoke a dangerous condition called status epilepticus Seizures that last longer than five minutes should be treated as a medical emergency. -*Injury*. The motions that occur during frontal lobe seizures sometimes result in injury to the person experiencing the seizure. -*Other brain functions*. Depending on the frequency and duration of seizures, frontal lobe epilepsy may affect memory, motor skills and other brain functions.. -*Sudden unexplained death in epilepsy (SUDEP)*. For unknown reasons, people who have seizures have a greater than average risk of dying unexpectedly. Possible factors include heart or breathing problems, perhaps related to genetic abnormalities. Controlling seizures as well as possible with medication appears to be the best prevention for SUDEP.

Generalized Tonic/Clonic (GTCS) phases

-*Tonic phase*. Loss of consciousness occurs, and the muscles suddenly contract and cause the person to fall down. This phase tends to last about 10 to 20 seconds. -*Clonic phase*. The muscles go into rhythmic contractions, alternately flexing and relaxing. Convulsions usually last one to two minutes or less. -*A scream*. Some people may cry out at the beginning of a seizure. -*Loss of bowel and bladder control*. This may happen during or following a seizure. -*Unresponsiveness after convulsions.* Unconsciousness may persist for several minutes after the convulsion has ended. -*Confusion*. A period of disorientation often follows a GTCS. This is referred to as postictal confusion. -*Fatigue*. Sleepiness is common after a GTCS. -*Severe headache.* Headaches may occur after a GTCS.

Postictal State

-After a seizure (postictal state) — For many seizure types, patients may be unaware during the seizure. They may have no memory of the event. -*The period following a seizure is called the postictal state.* During this time, the pt. may be confused and tired, and may develop a throbbing headache. Duration- several minutes, although it can last for hours or even days. -In some patients, the postictal period comes with certain symptoms. For example, you may experience mild to severe weakness in a hand, arm, or leg. Other people have difficulty speaking or experience temporary (partial) vision loss or other types of sensory loss. These can be important clues about the type of seizure and the part of the brain that was affected during the seizure. -*Allow the patient to rest and do not offer fluids until the LOC returns to normal.*

Post-ictal phase (recovery): know nursing assessments and interventions

-After a seizure (postictal state) — For many seizure types, patients may be unaware during the seizure. They may have no memory of the event. -The period following a seizure is called the postictal state. During this time, the pt. may be confused and tired, and may develop a throbbing headache. Duration- several minutes, although it can last for hours or even days. -In some patients, the postictal period comes with certain symptoms. For example, you may experience mild to severe weakness in a hand, arm, or leg. Other people have difficulty speaking or experience temporary (partial) vision loss or other types of sensory loss. These can be important clues about the type of seizure and the part of the brain that was affected during the seizure. -Allow the patient to rest and do not offer fluids until the LOC returns to normal. POSTICTAL STAGE The postictal stage occurs after the ictus or active stage of the seizure. As the seizure ends, the postictal phase occurs. This is the recovery period after the seizure. Some people recover immediately, while others may take minutes to hours to feel like their usual self. The type of seizure, as well as what part of the brain the seizure impacts, affects the recovery period — how long it may last and what may occur during it.

Labs and vital signs for health alterations?

-Electroencephalogram (EEG): for abnormal brain activity. The person is watched during a seizure event while the EEG records brain activity and a video camera records physical activity. Hold all seizure meds, NPO, no benzos. -Brain scans: Computerized tomography (CT) scan and magnetic resonance imaging (MRI) look at the structure of the brain. A PET scan checks the brain's activity and finds problems in how it works. A brain SPECT scan measures blood flow in the brain. A scan done during a seizure and one done between seizures are compared so that the part of the brain where the seizures start can be found. -Blood tests: Blood samples may be taken to check for causes or triggers of seizure such as infections, lead poisoning, anemia and diabetes. -Lumbar puncture: A sample of fluid from the space that surrounds the spinal cord and nerve roots is checked to see if an infection is the cause of the seizure. -Other tests may be done to measure motor skills, behavior and cognition to see how the epilepsy is affecting the person.

Neurogenic Shock

-Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. -Hypervolemia is indicated by rapid and bounding pulse and edema. -Autonomic dysreflexia occurs after neurogenic shock abates. Signs of sepsis would include elevated temperature, increased heart rate, and increased respiratory rate.

Education for Antieleptics

-Take medication as prescribed -Obtain blood levels as ordered. -Be able to state common side effects and when to call the MD. -Be able to state drug -drug interactions- ex warfarin should not be taken with Dilantin -Grapefruit juice may interfere with these medications. -Do not stop taking because of the I am cured syndrome. -Carry information about what drugs, dose you are taking.

Treatment for Epilepsy

-The goal of seizure treatment is to allow the patient to function normally, such as driving a car and going to work or school. Seizures can be treated with medication, surgery, or a combination of both. -Antiseizure or anticonvulsant medications can cause drowsiness, interfere with thinking, and interfere with other medications, so it is important that the primary care provider and pharmacist know all medications (prescription and over-the-counter), vitamins, herbs, or other supplements a patient may be taking. -Surgeries include the use of a vagus nerve stimulator. Less often, surgery to block the area where the seizure begins can be performed. -In children, epilepsy may also be controlled through a ketogenic diet. A ketogenic diet is high in fat, low in carbohydrates, and low in calories. This diet may stunt growth and must be supervised by providers and dieticians specially trained in ketogenic diets and monitoring.

Define and give examples of different types of incontinence:Transient, Stress, Urge, Overflow, Functional, Reflex, and Total incontinence.

-Transient incontinence: NEW onset likely caused by something outside urinary tract (meds, acute illness, inaccessible toilets, impaired mobility); DIAPERS: Delirium, Infection, Atrophic urethritis, Pharmaceuticals, Psychological, Excess urine output, Restricted mobility, and Stool impaction. -Stress incontinence: loss of urine (usually <50 mL) occurring with increased abdominal pressure from standing, sneezing/coughing, laughing, running, or heavy lifting -Urge incontinence: involuntary loss of urine associated with a strong, sudden urge to void; tx: anticholinergics, antihistamines, diet therapy (avoid caffeine/alcohol); exercises, bladder training. -Overflow incontinence: overfull bladder contracts on its won, some urine comes out, but obstruction prevents complete emptying, common in men with severe BPH. -Functional incontinence: experience incontinence b/c of difficulty or inability to reach toilet on time -Reflex incontinence: predictable urine loss with non sensation of urge, voiding, or bladder fullness -Total incontinence: continuous, unpredictable loss of urine w/out distension or awareness of bladder fullness

TURP post-op care?

-Watch for excessive bleeding, pain with bladder spasms, urinary incontinence, and infxn -Triple lumen catheter for bladder irrigation -Sterile NS continuous irrigation -Input and output MUST match -Peri-care -Avoid activities that increase abdominal pressure like sitting or walking a long time, straining -Sphincter tone-Kegels -It may take weeks to gain control of urine; continence can improve for up to 12 months

Teaching - Special considrations

-Women and teenage girls may experience seizures right before the menstrual period. Hormonal changes may be responsible and seizure medications may need to be adjusted before the menstrual period. -Some women with epilepsy have problems getting pregnant and when pregnant may have complications to the baby from the medications and/or experience more seizures during pregnancy. Complications to the baby are generally rare, with over 90% of babies born without problems. -Sleeping patterns, alcohol, and other medications can affect seizure threshold. Sleeping patterns should be consistent to avoid insomnia. Avoid alcohol, especially if it is known to bring on seizures. *Seizure patients should not start or stop any medications, vitamins, herbs, or other supplements without consulting a primary care provider and pharmacist.*

The nurse is caring for a patient with a high fever and the diagnosis is pyelonephritis. The nurse will implement all of the following interventions to promote healing. Select all that apply. A. Administer an antipyretic such as Tylenol. B. Restrict fluids C. Administer antibiotics D. Teach patients how to avoid UTI's E. Administer pain medication

A. Administer an antipyretic such as Tylenol. C. Administer antibiotics D. Teach patients how to avoid UTI's E. Administer pain medication Do NOT want to restrict fluids

Absence Seizures: The nurse is assessing a client with a history of absence seizures. Which clinical manifestation does the nurse assess for? A. Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, patting, and picking at clothing B. Intermittent rigidity C. Sudden loss of muscle tone D. Brief jerking of the extremities

A. Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, patting, and picking at clothing

Absence Seizures: The nurse is assessing a client with a history of absence seizures. Which clinical manifestation does the nurse assess for? A. Automatisms- lip smacking B. Intermittent rigidity C. Sudden loss of muscle tone D. Brief jerking of the extremities

A. Automatisms- lip smacking

Epidural hematoma: The patient had a head injury with a loss of consciousness. They are in the ER chatting away when suddenly the patient has a change in LOC. The patient now has a fixed dilated pupil. The nurse suspects an epidural hematoma. What is the first priority? A. Call a rapid response and do vital signs q 5 min. B. Notify the patient's next of kin. C. Administer a fluid bolus and start a second IV D. Notify the provider

A. Call a rapid response and do vital signs q 5 min.

The nurse is taking care of a patient who after a head injury briefly lost consciousness and has a diagnosis of Concussion. As part of the discharge instructions the nurse would instruct the patient on the following: A. How would the patient know if they were getting worse/when to seek help B. Should they go back to physical activity? C. What is the danger of repeated concussions?

A. N/V, change in LOC, worsening headache, vision changes - CALL 911 B. NO C. Brain damage -Don't let fall asleep, decrease stimulation (dim lights, quiet environment)

SCI: A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse's first action? A. Palpate the area over the bladder for distention. B. Place the client in the Trendelenburg position. C. Administer oxygen via a nasal cannula. D. Perform bilateral carotid massage.

A. Palpate the area over the bladder for distention. (Autonomic dysreflexia)

A 78-year-old woman is at her annual checkup with her health care provider. She seems very embarrassed about asking if it's normal to "leak" urine when coughing or laughing, especially at her age. She has given birth to five children. What is the nurse's best response to this question? A. "Involuntary loss of urine or incontinence is not a normal consequence of childbirth or aging." B. "As we get older, our bodies do not function as well as when we were younger." C. "The unintentional loss of urine can be temporary or permanent depending on the cause." D. "The most likely cause of your urine leakage is obstruction of the urethra with a kidney stone."

ANS: A. "Involuntary loss of urine or incontinence is not a normal consequence of childbirth or aging." Incontinence is not a normal response to aging or childbirth. It is often stigmatizing and not reported, which results in social isolation and lack of treatment. Responses B and C are true, but do not address the patient's question. Response D is not true for the type of incontinence this patient may have.

Absence seizures

Absence seizures involve brief, sudden lapses of consciousness. They're more common in children than in adults. Someone having an absence seizure may look like he or she is staring blankly into space for a few seconds. Then, there is a quick return to a normal level of alertness. This type of seizure usually doesn't lead to physical injury. Some patients have up to 100 per day. Absence seizures usually can be controlled with anti-seizure medications. Some children who have them also develop other seizures. Many children outgrow absence seizures in their teens.

Sx of absence seizures

An indication of simple absence seizure is a vacant stare, which may be mistaken for a lapse in attention that lasts about 10 seconds, though it may last as long as 20 seconds, without any confusion, headache or drowsiness afterward. Signs and symptoms of absence seizures include: Sudden stop in motion without falling Lip smacking Eyelid flutters Chewing motions Finger rubbing Small movements of both hands Afterward, there's no memory of the incident. Some people have many episodes daily, which interfere with school or daily activities.

Aura - Temporal lobe seizure/Focal

An unusual sensation (aura) may precede a temporal lobe seizure, acting as a warning. Not everyone who has temporal lobe seizures has auras, and not everyone who has auras remembers them. The aura is actually the first part of a focal seizure before consciousness is impaired. Examples of auras include: A sudden sense of unprovoked fear or joy A deja vu experience — a feeling that what's happening has happened before A sudden or strange odor or taste A rising sensation in the abdomen, similar to being on a roller coaster

Which patient is at greatest risk of developing a kidney stone? A. African-American female with family history of kidney stones B. Overweight Caucasian male C. Female with history of frequent urinary tract infections D. Hispanic/Latino female who eats animal protein at every meal

Answer: B Rationale: Anyone can form a kidney stone, but you may be more likely to have one if you are male, Caucasian, very overweight, have had kidney infections, have a family member with kidney stones, have had kidney stones before, eat a lot of animal protein (such as meat and eggs), or do not drink enough liquids.

A 21-year-old male reports burning and difficulty with urination. What priority question would obtain information about the patient's chief complaint? A. "How long have you had these symptoms?" B. "Do you have low back pain?" C. "Are you sexually active?" D. "Have you had a fever in the past 24 hours?"

Answer: C Rationale: The most common cause of urethritis in men is sexually transmitted diseases (STDs). These include gonorrhea or nonspecific urethritis caused by Ureaplasma (a gram-negative bacterium), Chlamydia (a sexually transmitted gram-negative bacterium), or Trichomonas vaginalis (a protozoan found in both the male and female genital tracts).

What does AD refer to?

Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients aren't prone to dysreflexia.

Head Injury: A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? A Position the client flat in bed and place a 4x4 in the ear. B Check the fluid for dextrose with a dipstick and collect a specimen on a 4x4 C Suction the nose to maintain airway patency D Insert nasal and ear packing with sterile gauze 4x4

B Check the fluid for dextrose with a dipstick and collect a specimen on a 4x4 (Glucose - checking for CSF)

The wife of a patient who has undergone a TURP and has continuous bladder irrigation asks the nurse about the purpose of the continuous bladder irrigation. Which response by the nurse is appropriate? A. "The bladder irrigation is needed to stop the postoperative bleeding in the bladder." B. "The irrigation is needed to keep the catheter from being occluded by blood clots." C. "Normal production of urine is maintained with the irrigations until healing occurs." D. "Antibiotics are being administered into the bladder with the irrigation solution."

B. "The irrigation is needed to keep the catheter from being occluded by blood clots."

A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should you take first? A. Administer the ordered acetaminophen (Tylenol). B. Check the Foley tubing for kinks or obstruction. C. Adjust the temperature in the patient's room. D. Notify the physician about the change in status.

B. Check the Foley tubing for kinks or obstruction.

Delirium: Which of the following, if assessed in a patient, will the healthcare provider identify as a risk factor for the development of delirium? Select all A. Decreased physical activity B. Lack of sleep C. Administration of opioids D. Lack of visitors E. Hospitalization

B. Lack of sleep C. Administration of opioids E. Hospitalization

Raccoon Eyes: The patient presents with raccoon eyes, battle sign, bleeding in the inner ear and clear fluid draining from the nose. The diagnosis is Basilar skull fracture. The top priority for preventing further injury means the nurse will: A. Prepare the patient for the OR B. Proceed as there is a co-existing C-spine injury C. Culture the clear fluid D. Pack the nose with 4x4s

B. Proceed as there is a co-existing C-spine injury

Bladder Training: Which of the following interventions describes an initial appropriate bladder program for a client in rehabilitation for spinal cord injury? A. Insert an indwelling urinary catheter to straight drainage B. Schedule intermittent catheterization every 2 to 4 hours C. Perform a straight catheterization every 8 hours while awake D. Wait to catheterize the patient until the bladder scan shows the bladder is full.

B. Schedule intermittent catheterization every 2 to 4 hours Intermittent catherization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Indwelling catheters may predispose the client to infection and are removed as soon as possible. Allowing the bladder to be full is not good practice.

GTCS Priority Action: The nurse is caring for a client with a history of epilepsy who suddenly begins to experience a tonic-clonic seizure and loses consciousness. What is the nurse's priority action? A. Restrain the clients extremities B. Turn the client's head to the side. C. Take the client's blood pressure. D. Place an airway into the client's mouth.

B. Turn the client's head to the side. -The nurse should turn the client's head to the side to prevent aspiration and allow drainage of secretions. -The client should not be restrained nor an airway placed in his or her mouth during the seizure because these actions increase seizure activity and can harm the client. -Vital signs are measured in the postictal phase of the seizure.

Renal function lab tests & values: BUN: indirect/rough measurement of renal function and GFR; also measurement of liver function; part of normal bloodwork Serum creatinine: used to dx impaired renal function; amount of creatinine in blood; estimate GFR Urine tests, various Serum osmolality: gain info about fluid status and electrolyte imbalance; helpful in illnesses involving ADH Creatinine clearance: measure GFR of kidneys. Creatinine is catabolic product of creatinine phosphate, used in skeletal muscle contraction. Daily production of creatinine depends on muscle mass; excreted entirely by kidneys and therefore directly proportional to GFR

BUN (blood urea nitrogen): Adult= 10-20 mg/dL; >20 = abnml; elderly may be slightly higher; >100 critical value = serious renal impairment of renal function Serum creatinine: 0.6-1.2 mg/dL Urine: specific gravity: 1.010-1.025 osmolality: 285-295 mOsm/kg H20 [normal is 3:1, urine:serum osmolality] chemistry creatinine clearance (CrCl): male=107-130 mL/min female=87-107 mL/min; values decrease 6.5 mL/min/decade of life after 20 years with decline of GFR (eGFR: >60 mL/min/1.73m2) Urinalysis with microscopy

The nurse is caring for a patient with pyelonephritis what are the signs and symptoms of this condition?

Bacterial infection in kidney and renal pelvis (upper urinary tract) Acute symptoms: -Fever, chills, tachycardia, tachypnea -Flank, back, or loin pain -Abdominal discomfort -Turning, nausea and vomiting, urgency, frequency, nocturia -General malaise or fatigue

Pyelonephritis

Bacterial infection in kidney and renal pelvis (upper urinary tract) Acute symptoms: Fever, chills, tachycardia, tachypnea Flank, back, or loin pain Abdominal discomfort Turning, nausea and vomiting, urgency, frequency, nocturia General malaise or fatigue

ND Acute pain r/t surgery and bladder spasms rationale?

Bladder spasms frequently occur after prostate procedures and incisional pain will occur if an open surgery is completed due to stimulating actions on nociceptors, which are responsible for pain sensation.

When does Decerebrate or extensor posturing occur?

Brain herniation = supratentorial herniation: develop sequential s/s of ocular, motor, and respiratory function. Two major types of supratentorial herniation: cingulate and transtentorial Changes in consciousness and coma may follow due to compression of midbrain against the opposite tentorial edge. Decerebrate posturing may develop, followed by dilated, fixed pupils; flaccidity; and respiratory arrest.

AD: Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? A A client with a brain injury B A client with a herniated disc C A client with a high cervical spine injury D A client with a stroke

C A client with a high cervical spine injury

SCI: A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? A Autonomic dysreflexia B Hypervolemia C Neurogenic shock D Sepsis

C Neurogenic shock

Increased ICP: Which patient below with ICP is experiencing Cushing's Triad? A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12

C. BP 200/60, HR 50, RR 8 Cushing's Triad: three primary signs that often indicate ICP: -Increase systolic BP -Decrease HR -Decrease RR These vital signs represent Cushing's triad. There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and bradypnea. *Opposite of shock: decrease BP, increase HR & RR

SCI: The nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury. Which action does the nurse implement? A. Massage the reddened areas with a barrier cream. B. Perform hip flexion and extension range-of-motion (ROM) exercises. C. Reposition the client so that the reddened area does not bear weight. D. Ensure that the client sits in a chair at least once each shift.

C. Reposition the client so that the reddened area does not bear weight.

Altered LOC: A client was admitted after sustaining a closed head injury. Several hours later, the nurse assesses that the client is more lethargic and confused, is mumbling her speech, and is very difficult to arouse. What is the source of her concern? A. The client is overtired from the events of the day. B. The client is over-sedated. C. The client's brain injury may be worsening. D. The client's ICP may be decreasing.

C. The client's brain injury may be worsening.

Nursing Dx Urinary Incontinence: During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? A. Urinary stress incontinence B. Functional urinary incontinence C. Urge incontinence D. Reflex urinary incontinence

C. Urge incontinence C The key phrase is "the urge to void" option one occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. Option two occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Option three is involuntary loss of urine related to impaired function.

Functional Incontinence: A client has functional urinary incontinence. Which instruction by the nurse to the client and family helps meet an expected outcome for this condition? A. "You must clean around your catheter daily with soap and water." C. "Operations to repair your bladder are available, and you can consider these." D. "Buy slacks with elastic waistbands that are easy to pull down."

D. "Buy slacks with elastic waistbands that are easy to pull down." Functional urinary incontinence occurs as the result of problems not related to the client's bladder, such as trouble ambulating or difficulty accessing the toilet. One goal is that the client will be able to manage his or her clothing independently. Elastic waistband slacks that are easy to pull down can help the client get on the toilet in time to void. The other instructions do not relate to functional urinary incontinence.

Dementia: A patient diagnosed with dementia is prescribed a medication that inhibits acetylcholinesterase. Which of the following accurately explains how this medication benefits the patient? A. Decreased levels of acetylcholine will help decrease the patient's anxiety B. Acetylcholine increases norepinephrine activity and decreases depression C. Inhibition of acetylcholinesterase improves the patient's motor function D. Acetylcholine is needed for memory and problem solving

D. Acetylcholine is needed for memory and problem solving

Your patient has complaints of severe right-sided flank pain, nausea, vomiting and restlessness. He appears slightly pale and is diaphoretic. Vital signs are BP 140/90 mmHg, Pulse 118 beats/min., respirations 33 breaths/minute, and temperature, 98.0F. Which subjective data supports a diagnosis of renal calculi? A. Pain radiating to the right upper quadrant B. History of mild flu symptoms last week C. Dark-colored coffee-ground emesis D. Dark, scanty urine output

D. Dark, scanty urine output -low output, hematuria = blood in urine (common) caused by stone's passage through the urinary tract. The urine appears dark, tests positive for blood and is typically scant.

SCI: A client who has a lower motor neuron injury experiences a flaccid bowel elimination pattern. Which action does the nurse implement to assist in relieving this client's constipation? A. Pouring warm water over the perineum B. Tapping the abdomen from left to right C. Administering daily tap water enemas D. Implementing a consistent daily time for elimination

D. Implementing a consistent daily time for elimination (digital evacuation b/c flaccid paralysis)

Parkinson's and risk for respiratory complications: The nurse is caring for a client with Parkinson's disease. Which intervention does the nurse implement to prevent respiratory complications in the client? A. Keep an oral airway at the bedside. B. Ensure fluid intake of at least 3 L/day. C. Teach the client pursed-lip breathing techniques. D. Maintain the head of the bed at 30 degrees or greater. Elevation of the back rest will help prevent aspiration.

D. Maintain the head of the bed at 30 degrees or greater. Elevation of the back rest will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson's disease.

A patient undergoing a TURP returns from surgery with a three-way urinary catheter with continuous bladder irrigation in place. The nurse observes that the urine output has decreased and the urine is clear red with multiple clots. The patient is complaining of painful bladder spasms. The most appropriate action by the nurse is to: A. Administer the ordered IV morphine sulfate, 4 mg. B. Increase the flow rate of the continuous bladder irrigation. C, Give the ordered the belladonna and opium suppository. D. Manually instill 50 ml of saline and try to remove the clots.

D. Manually instill 50 ml of saline and try to remove the clots. NEED to remove clots

Seizures: Auras are typical of A. Primary GTCS B. Absence seizures C. Myoclonic seizures D. Partial seizures

D. Partial seizures

SCI: Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time? A. Level of consciousness and orientation B. Heart rate and rhythm C. Muscle strength and reflexes D. Respiratory pattern and airway

D. Respiratory pattern and airway

Assessment Seizure: A client with epilepsy develops stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How does the nurse document this seizure activity? A. Atonic Seizure B. Absence Seizure C. Myoclonic Seizure D. Tonic Clonic Seizure

D. Tonic Clonic Seizure Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. The other seizures do not manifest in this manner.

Aphasia: When reviewing the medical record of a patient diagnosed with Alzheimer disease (AD), the healthcare provider notes the patient is aphasic. Which behavior supports this finding? A. Difficulty moving lower extremities B. Unable to recognize objects C. Difficulty swallowing D. Unable to speak

D. Unable to speak If pt unable to swallow, the are unable to speak Aphasia: loss of ability to swallow and/or loss of language or ability to communicate

MUST know difference between DECEREBRATE and DECORTICATE posturing/rigidity. (PG 922 in Porth)

Decorticate/FLEXOR posturing: upper arms are held at sides, with elbows, wrists, and fingers flexed. The legs are extended and internally rotated. The feet are plantar flexed. (arms/elbows = FLEXED/BENT) Decerebrate/EXTENSOR posturing: jaws are clenched and neck extended. Arms are adducted and stiffly extended at elbows with forearms pronated, writs and fingers flexed. (arms/elbows = EXTENDED/STRAIGHT)

Stress incontinence

Definition: the person reports loss of urine (usually < 50 mL) occurring with increased intra-abdominal pressure from standing, sneezing, coughing, laughing, running, or lifting heavy objects Risk factors: childbearing, esp. grand multip; weight gain/obesity; pelvic floor weakness or prolapse; Smoking; chronic lung disease or acute respiratory disease Interventions: Journaling, behavioral interventions, diet modification Pelvic floor (Kegel) exercises Refer to specialist for pelvic floor muscle exercise retraining Diet therapy: weight loss Drug therapy—estrogen Surgery for prolapse Vaginal cone therapy

What is Desmopressin?

Desmopressin is a man-made form of vasopressin and is used to replace a low level of vasopressin (ADH). This medication helps to control increased thirst and too much urination due to these conditions, and helps prevent dehydration. Desmopressin is also used to control nighttime bedwetting in children.

What are the interventions for ND Acute pain r/t surgery and bladder spasms?

Ensure that drainage system is not blocked Administer meds for relief of bladder spasms (antispasmotics) ---Belladonna and opium suppositories ---Propantheline bromide (Pro-Banthine) or immediate release oxybutynin (Ditropan IR) Have proper interventions for SE of drugs ---Dry mouth, drowsiness, acute confusion in older clients ---Stool softeners (docusate/Colace) should be give since straining at stool can precipitate bleeding from operative site.

Etiology frontal lobe seizures

Etiology -Frontal lobe seizures, or frontal lobe epilepsy, may be caused by abnormalities — such as tumors, stroke, infection or traumatic injuries — in the brain's frontal lobes. -Frontal lobe seizures are also associated with a rare inherited disorder called autosomal dominant nocturnal frontal lobe epilepsy. If one of your parents has this form of frontal lobe epilepsy, you have a 50 percent chance of inheriting this abnormal gene that causes this disorder and developing the disease yourself. -In about half of cases, however, the cause of frontal lobe epilepsy remains unknown.

Causes of seizures (TRIGGERS)

Failure to take medication correctly (noncompliance) Variation in medication effectiveness Sleep deprivation Stress/ Illness Hypoglycemia/dehydration Alcohol/drug use or withdrawal Hormonal fluctuations Flashing lights or other triggers

Pediatric Febrile Seizures

Febrile seizures are convulsions that occur in a child who is between six months and five years of age and has a temperature greater than 100.4º F (38º C). The majority of febrile seizures occur in children between 12 and 18 months of age. No lab tests are recommended for a simple febrile seizure- control fever and infection. May be associated with: Genetic Cause Viral illness Vaccinations High fever Zinc and Iron deficiencies Intravenous lorazepam (Ativan) in a dose of 0.1 mg per kg is the treatment of choice for acute tonicclonic pediatric seizures. A Cochrane review found lorazepam to be as effective as diazepam (Valium), with fewer adverse effects and less need for additional antiepileptic agents. The same study found *buccal midazolam to be superior to rectal diazepam (Diastat)* when intravenous administration is not possible.

Assessment of pupil size.

Fixed and dilated pupils are a poor prognostic sign Unilateral dilated pupil, Assess TBI [patients for pupil size and reaction to light. Asymmetric (uneven pupils are treated as brain herniation unless proven otherwise. Assess for diplopia Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage

LMN: Bowel elimination

For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client, which includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. The other interventions do not assist this client.

S/s frontal lobe seizures

Frontal lobe seizures usually last less than 30 seconds and often occur during sleep. In some cases, recovery may be immediate. Signs and symptoms of frontal lobe seizures may include: -Head and eye movement to one side -Complete or partial unresponsiveness or difficulty speaking -Explosive screams, including profanities, or laughter -Abnormal body posturing, such as one arm extending while the other flexes, as if the person is posing like a fencer -Repetitive movements, such as rocking, bicycle pedaling or pelvic thrusting

Define type of seizures: generalized

Generalized: involves both hemispheres of brain -Tonic-Clonic: 2-5 minutes, begins with stiffening then rhythmic jerking of all extremities -Tonic: abrupt increase in muscle tone, loss of consciousness, and autonomic changes. Lasts 30 seconds-several minutes -Clonic: muscle contraction and relaxation. Lasts several minutes -Absence: brief loss of consciousness that consists of staring and automatisms. Mostly in children, may happen 100+/day -Myoclonic: brief jerking or stiffening of extremities, may be symmetric or asymmetric lasting just a few seconds. -Atonic (akinetic): sudden loss of muscle tone causing person to fall, lasting for seconds, and most resistant to medications.

Head injury: Lab testing

Halo sign - Dextrostix or Tes-Tape test is done and fluid is dripped onto a 4x4 the result is Positive if it looks like the picture below Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. Placing the client flat in bed may increase ICP and promote pulmonary aspiration. The nose wouldn't be suctioned because of the risk for suctioning brain tissue through the sinuses. Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection.

Nursing Assessment: emergency seizure care

If you see someone having a tonic-clonic seizure: -Try to lay person on floor and gently turn him onto his side -Move objects in area out of the way to prevent injury -Do NOT try to stop the person's movements -Place something soft and flat under the head -Do NOT put anything in the person's mouth -Remove items fro the head and anything around the neck that might restrict breathing -Time the seizure. If it lasts longer than 5 minutes or is followed by another seizure, seek emergency treatment (SE)

S/s renal calculi, dx, & risk factors

Increase incidence in males N/V Agonizing flank pain, may radiate to: groin, testicles, abdominal area Sharp, sudden, severe pain: may be intermittent depending on stone movement Hematuria Dysuria Urinary frequency Diagnosis: US, CT, IVP, renal stone analysis, retrograde pyelogram, cystoscopy, measure urine pH Risk factors - etiology: infection, urinary stasis & retention, immobility, dehydration, increase uric acid, increase urinary oxalate, and family hx

Causes of urinary tract obstruction.

Lower urinary tract: BPH, calculi, urethral strictures, or tumors Upper urinary tract: calculi, trauma, tumor, aneurysms, or congenital anomaly

Causes of transient incontinence.

NEW ONSET is LIKELY to be caused by something OUTSIDE the urinary tract (meds, acute illness, inaccessible toilets, impaired mobility) Other transient causes Coughing from resp. infection; pressure on diaphragm form hyperinflated lungs RT acute worsening of respiratory disease Meds Acute confusion (early sign of UTI in elderly) UTI, Atrophic vaginitis Metabolic issues (polyuria form DM) Stool impaction, especially in kids & elderly DIAPERS: Delirium, Infection, Atrophic urethritis, Pharmaceuticals, Psychological, Excess urine output, Restricted mobility, and Stool impaction.

Patients with TBI

Obtain an history- what happened was there amnesia, change in LOC was the person unconscious? Was there drugs or alcohol on board? Any seizure or hx of seizures? All elderly must be screened for abuse and neglect with TBI Assess for increased ICP signs, hypoxia, hypotension, hypercarbia (with co2 monitor) may cause cerebral edema Airway, breathing and circulation- always treat head injury as cervical spine injury also. Assess for spinal cord injury also. Injury to brainstem may cause Cheyne -stokes resp. Monitor VS watch for Cushings triad Glascow coma scale Know the numbers for results. (higher the number the better the patient) Watch for irritability, restlessness and disorientation

SCI Skin Care

Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. ROM exercises are used to prevent contractures. The reddened areas should be assessed for blanching. If the skin does not blanch, the area is vulnerable to breakdown. *Appropriate interventions to relieve pressure on these areas through positioning, assistive devices, and skin protection should then be used.*

Some anti-seizure medications, indications, and nursing interventions (NI)

Tegratol for partial, generalized, tonic-clonic seizures; NI: monitor for H/A, dizziness, diplopia, N/V, leukopenia Depakote for all types of seizures; NI: monitor for hair loss, tremor, increased liver enzymes, bruising, N/V, CBC, PT, PTT, & AST Keppra for partial seizures; NI: monitor for renal function, gait, & coordination problems Dilantin for all types, except absence, myoclonic & atonic seizures, for SE; NI: monitor for GI upset, gingival hyperplasia, anemia, ataxia, nystagmus, CBC, CA levels, and therapeutic levels Klonopin for absence, myoclonic & akinetic seizures; NI: monitor liver function Valium/Ativan for SE; NI: monitor airway, breathing, & circulation Topamax as adjunctive therapy for intractable partial seizures; NI: monitor for ataxia, confusion, dizziness, fatigue, and increased renal calculi

Autonomic Dysreflexia (AD)

The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.

Vagus Nerve Stimulation

Vagus nerve stimulation involves implantation of a device that stimulates the vagus nerve with electrical impulses. -Used to treat epilepsy when other treatments haven't worked, also a treatment for; treatment resistant depression -Vagus nerve stimulation, a device is surgically implanted under the skin of the chest, and a wire is threaded under the skin connecting the device to the left vagus nerve. -*The right vagus nerve is not used because it carries fibers that supply nerves to the heart* When activated, the device sends electrical signals along the vagus nerve to your brainstem, which then sends signals to certain areas in your brain. -New, noninvasive vagus nerve stimulation devices, which do not require surgical implantation, have been approved for use in Europe to treat epilepsy, depression and pain but have not yet been approved for use in the U.S.

Change is indication of deterioration: A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 130/72, pulse 90, respirations 32 b. Blood pressure 148/78, pulse 112, respirations 28 c. Blood pressure 156/60, pulse 60, respirations 14 d. Blood pressure 110/70, pulse 120, respirations 30

c. Blood pressure 156/60, pulse 60, respirations 14 Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

Frontal lobe seizures

*Frontal lobe seizures are a common form of epilepsy, a neurological disorder in which clusters of brain cells send abnormal signals and cause seizures. These types of seizures originate in the front of the brain.* -Frontal lobe seizures may also be caused by abnormal brain tissue, infection, injury, stroke, tumors or other conditions. -The frontal lobe has many important functions, frontal lobe seizures may produce a number of unusual symptoms that can appear to be related to a psychiatric problem or a sleep disorder. - *Frontal lobe seizures often occur during sleep* and may feature bicycle pedaling motions and pelvic thrusting. Some people scream profanities or laugh during frontal lobe seizures. -Medications usually can control frontal lobe seizures, but *surgery or an electrical stimulation device may be options if anti-epileptic drugs aren't effective.*

Which medications may cause incontinence?

*Narcotics & sedatives diminish awareness of bladder fullness *Adrenergic agents (decongestants, some asthma meds) increase sphincter tone, make it harder to empty bladder *Almost all drugs with anticholinergic (TCA anti-depressants, anti-Parkinson meds, anti-spasmodics, anti-histamines, atropine, anti-arrhythmics, opioids) effects cause urinary retention

What to expect s/p TURP?

Blood clots 24-36 hours Foley catheter 2-4 days

What organism is the most common cause of pyelonephritis?

E. coli

A temporal lobe seizure is a focal seizure that originates in one of the temporal lobes. Etiology is unknown, but result of factors:

The etiology of temporal lobe seizures remains unknown. However, they can be a result of a number of factors, including: Traumatic brain injury Infections, such as encephalitis or meningitis, or a history of such infections A process that causes scarring (gliosis) in a part of the temporal lobe called the hippocampus Blood vessel malformations in the brain Stroke Brain tumors Genetic syndromes During normal waking and sleeping, the brain cells produce varying electrical activity. If the electrical activity in many brain cells becomes abnormally synchronized, a seizure may occur. If this happens in just one area of the brain, the result is a focal seizure

The patient says that she vaguely recalls advice from her OB/GYN about Kegel exercises, but does not recall how to perform them. 1. How should the nurse describe this procedure? 2. How many repetitions of this exercise should be recommended that she perform?

1. See directions in your text. 2, Do three repetitions of each set of exercises in each of 3 positions: lying down, sitting up, and standing. If realistic, begin with five sets of 9 exercises (3 per each position), and as symptoms improve, go down to three times a day. 3. Caution the patient that it may take as long as 3 months to notice improvement.

State and describe 5 interventions from Laurin's page: 1. one-way conversation, 2. eye contact, 3. your presence, 4. touch, 5. shared experience, 6, demonstration, and 7. technology

1. one-way conversation: Just think out loud. Share with her some of the things that have happened in your life since the last time you spoke to her; read to her 2. eye-contact: If words fail you, just look her in the eye and smile. Watch her face for reactions when you talk to her. This is one way to communicate with Laurin where you'll be on equal footing. In fact, Laurin may be better than most people are at communicating with their eyes, since that is by far the main way she can connect with people. If you want to get her answering yes/no questions, she's able to answer those through blinking her eyes. Just establish with her that you know the code: zero blinks for no, one blink for yes. 3. Your presence: Just being in the room with Laurin can be a way to connect with her. Often, small children seem to get this right away. My twin nephews were five years old when they first met Laurin. Her condition didn't seem to inhibit them at all. They got close and touched her, talked to her, talked to each other, and just filled the room with light, joy and energy. 4. Touch: You do have to be a little delicate with this one, as there may be medical equipment such as catheters, feeding tubes, IVs, tracheostomy tubes, oxygen masks, etc. that you should be careful not to disturb. With Laurin, a gentle touch of the hand or arm, a stroke of the hair, or a kiss on the cheek or forehead seem to be welcome gestures of affection and friendship. Don't overdo it, though. She's not a lap dog. 5. Shared experience: If the non-verbal person can be taken for a car ride, you could go on a little sightseeing drive together. If she has a wheelchair, take her out for a walk on a nice day 6. Demonstration: This is where your high school drama skills can come into play. Re-enact something that happened to you. Show her how something works. Trot out some of your dance moves. Sing her a song. I've sung to her spontaneously a few times, and it really moves her. She tears up and gets emotional (in a good way!). It seems to minister to her deeply. 7. Technology: Laurin has been blessed with a unique piece of technology known as an eye-gaze computer. There is great potential for communication here, but there's a big learning curve. Laurin has had a few sessions with it, but she really needs someone who can spend some serious time working with her on it. Whenever she sees the computer, she gets so excited. I know she wants to learn. We've been letting her listen to Bible messages on her computer and she's never more alert.

Head Injury - D.I. The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: A Desmopressin (DDAVP, stimate) B Dexamethasone (Decadron) C Ethacrynic acid (Edecrin) D Mannitol (Osmitrol)

A Desmopressin (DDAVP, stimate) For vasoconstriction and decrease fluid loss via urine A complication of a head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally *requires treatment with desmopressin.* Dexamethasone, a glucocorticoid, is administered to treat cerebral edema. This medication may be ordered for the head injured patient. Ethacrynic acid and mannitol are diuretics, which would be contraindicated.

Increased ICP = Change in LOC = early indicator of deterioration

A decrease in the client's LOC is an early indicator of deterioration of the client's neurological status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

Seizures - risk for injury

A seizure is an abnormal sudden, excessive, uncontrollable electrical discharge in the brain that may result in: LOC changes Motor or sensory ability And/or behavior -Epilepsy is two or more seizures experienced by a person. It is a chronic reoccurring brain disorder. -Most seizures last from 30 seconds to 2 minutes and do not cause lasting harm. - It is a medical emergency if seizures last longer than 5 minutes or if a patient has many seizures and does not wake up between them.

A nurse is instructing a client who is scheduled for a transurethral resection of the prostate (TURP) about his postoperative care. Which of the following information should the nurse include in the teaching? A. "You may have a continuous sensation of needing to void even though you have a catheter." B. "You will be on bed rest for the first 2 days after the procedure." C. "You will be instructed to limit your fluid intake after the procedure." D. "Your urine should be clear yellow the evening after the surgery."

A. "You may have a continuous sensation of needing to void even though you have a catheter." -sensation of urinary urgency is common

A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? A. Unequal pupil size B. Decreasing systolic blood pressure C. Tachycardia D. Decreasing body temperature

A. Unequal pupil size

Before going home, the patient asks what can be done to fix her problem with urine leaking. Which teaching points should the nurse be sure to include? (Select all that apply.) A. First, keep a diary of episodes of incontinence. B. Pay attention to timing and circumstances of episodes C. Kegel exercises can help strengthen the muscles that prevent urine leakage. D. You may want to avoid caffeine and other bladder irritants. E. Be sure to drink less than 2 L of fluids every day, especially in the evening.

ANS: A, B, C, D The patient should consume at least 3 L of fluids per day, especially water.

The patient says that a friend mentioned taking antidepressant drugs when she had a similar problem, and asks if this could help herself. What is the nurse's best response? A. "Estrogen may be helpful because it can improve vaginal and urethral blood flow." B. "Tricyclic antidepressants such as imipramine have been helpful in relieving urinary incontinence." C. "An antispasmodic drug such as oxybutynin would probably be better." D. "Your problem may be different from your friend's, requiring a different solution."

ANS: B Responses A, C, and D do not address the patient's question. Response B is accurate, and a good suggestion would be that she discuss this option with her provider.

A nurse is providing discharge instructions to a client who is postoperative from a TURP. Which of the following instructions should the nurse include? (Select all that apply.) A. Avoid sexual intercourse for 3 months after the surgery. B. If urine appears bloody, stop activity and rest. C. Avoid drinking caffeinated beverages. D. Take a stool softener once a day. E. Treat pain with ibuprofen (Motrin).

B. If urine appears bloody, stop activity and rest. C. Avoid drinking caffeinated beverages. D. Take a stool softener once a day. Tx with Tylenol; NSAIDs increase risk of bleeding

A client is actively experiencing status epilepticus. Which prescribed medication does the nurse prepare to administer? A. Atropine B. Lorazepam (Ativan) C. Phenytoin (Dilantin) D. Morphine sulfate

B. Lorazepam (Ativan) Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atropine and morphine are not administered for seizure activity.

What are normal blood chemistry levels? [pp 614 Porth Table 24-1]

BUN: 8-20.0 mg/dL Creatinine: 0.6-1.2 mg/dL Sodium: 135-145 mEq/L Chloride: 98-106 mEq/L Potassium: 3.5-5 mEq/L CO2: 24-29 mEq/L Calcium: 8.5-10.5 mg/dL Phosphate: 2.5-4.5 mg/dL Uric acid, male: 2.4-7.4 mg/dL Uric acid, female: 1.4-5.8 mg/dL pH: 7.35-7.45

Later in the visit, the patient asks what could have caused her stress incontinence. What is the nurse's most accurate reply? A. "It could be due to a loss of awareness that urination is about to occur." B. "It most likely is related to drinking too many caffeinated beverages." C. "Do you take any diuretics for your blood pressure?" D. "It may be due to weakening of the bladder neck support that is associated with childbirth."

D. "It may be due to weakening of the bladder neck support that is associated with childbirth." Stress incontinence is the involuntary loss of urine during activities that increase abdominal and detrusor muscle pressure. It is often caused by weakening of the bladder neck support associated with childbirth. Urine loss occurs with physical exertion such as coughing, sneezing, or exercise.

A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? A. Widening pulse pressure B. Decrease in the pulse rate C. Dilated, fixed pupil D. Decrease in LOC

D. Decrease in LOC (early sign) Late signs: widening pulse pressure, bradycardia, and dilated, fixed pupils; also increase in systolic pressure and increase in body temperature

Normal values for routine UA.

General characteristics and measurements: Color: yellow-amber (darker indicates high specific gravity and small urine output) Turbidity: clear to slightly hazy Specific gravity: 1.010-1.025 with a normal fluid intake pH: 4.6-8.0 Chemical determination: Glucose: negative Ketones: negative Blood: negative Protein: negative Bilirubin: negative Urobilirubogen: 0.5-4.0 mg/d Nitrate for bacteria: negative Leukocyte esterase: negative Microscopic examination of sediment: Casts negative: occasional hyaline casts RBCs: negative or rare Crystals: negative (none) WBCs: negative or rare Epithelial cells: few

Causes of seizures

High fever, especially in infants Drug use, alcohol withdrawal Near-drowning or lack of oxygen from another cause Metabolic disturbances Head trauma Brain tumor, infection, stroke Complication of diabetes or pregnancy

Problems with urine outflow obstruction

Hydronephrosis, Hydroureter, and Urethral Stricture Hydronephrosis is caused by obstruction in the upper part of the ureter. Hydroureter is caused by obstruction in the lower part of the ureter.

Examples of GU abnormalities associated with increased incidence of UTIs: obstruction, urinary instrumentation, foreign body, metabolic disease/illness, urinary diversion, or functional abnormality

Obstruction: structure, congenital abnormality, tumor, prostatic hypertrophy, renal stone, renal cyst, diverticulum Urinary instrumentation: cystoscopy, prostatectomy Foreign body: indwelling catheter, ureteric stent, nephrostomy tube Metabolic dx: DM, post-renal transplantation Urinary diversion: ileal conduit Functional abnormality: neurogenic bladder, vesicoureteral reflux

Overflow incontinence

Overfull bladder contracts on its own, some urine comes out, but obstruction prevents complete emptying. Common in men with severe BPH. Interventions: Surgery to relieve obstruction: TURP Intermittent catheterization Bladder compression Drug therapy to reduce prostate size: finasteride Behavioral interventions

Define type of seizure: partial

Partial: begin in part of one cerebral hemisphere -complex-partial: causes syncope for 1-3 minutes; temporal lobe, psychomotor/temporal lobe seizures. Impairs consciousness; person may wander and have amnesia -simple-partial: consciousness intact. May experience one sided movement of extremities, unusual sensations, & autonomic changes

Urolithiasis (kidney stones)

Presence of calculi (stones) in urinary tract Assessment Pain-relief measures: Drug therapy: hydrochlorothiazide if calcium based stone; other drugs is oxalate stones Lithotripsy (blast with sound waves to break into smaller pieces) Surgical management Minimally invasive surgery Open surgical procedures

S/S Febrile seizures pediatrics

Signs and symptoms Simple febrile seizure The setting is fever in a child aged 6 months to 5 years The single seizure is generalized and lasts less than 15 minutes The child is otherwise neurologically healthy and without neurologic abnormality by examination or by developmental history Fever (and seizure) is not caused by meningitis, encephalitis, or any other illness affecting the brain The seizure is described as either a generalized clonic or a generalized tonic-clonic seizure Child may turn cyanotic

Urge incontinence

State in which a person experiences an involuntary loss of urine associated with a strong, sudden desire to void Interventions: Drugs—anticholinergics, antihistamines, others Diet therapy—avoid caffeine and alcohol Behavioral interventions—exercises, bladder training, habit training, electrical stimulation

Functional incontinence

State in which a person experiences incontinence because of a difficulty or inability to reach the toilet on time

Reflex incontinence

State in which a person experiences predictable involuntary urine loss with no sensation of urge, voiding, or bladder fullness Plan: self cath, bladder pacemakers Autonomic dysreflexia

Total incontinence

States in which a person experience continuous, unpredictable loss of urine without distention or awareness of bladder fullness Usually follows major or radical pelvic surgery or prostate, vaginal, or gyn cancers, major pelvic fractures or ruptured bladder Goal of care is management to prevent skin breakdown Men: condom caths

Renal calculi: Why do patients strain their urine? What nursing diagnosis will be a priority?

Strain urine to check for/save stones for analysis. Nursing Dx: Acute pain Risk of injury Risk of infection

Focal-Temporal Lobe Seizures

Temporal lobe seizures may impair the ability to respond to others. This type of temporal lobe seizure usually lasts 30 seconds to two minutes. Characteristic signs and symptoms include: Loss of awareness of surroundings Staring Lip smacking Repeated swallowing or chewing Unusual finger movements, such as picking motions After a temporal lobe seizure, the patient may have: A period of confusion and difficulty speaking Inability to recall what occurred during the seizure Unawareness of having had a seizure Extreme sleepiness In extreme cases, what starts as a temporal lobe seizure evolves into a generalized tonic-clonic seizure — featuring convulsions and loss of consciousness.

Which of the following are signs of increased ICP in infants?

Tense or bulging fontanels Separated sutures [McEwen's sign] Setting-sun eyes Irritability High-pitched cry Distended scalp veins Feeding problems Projectile vomiting

Risk factors: absence seizures

Risk factors Certain factors are common to children who have absence seizures, including: -Age. Absence seizures are more common in children between the ages of 4 and 14. -Sex. Absence seizures are more common in girls. -Family members who have seizures. Nearly half of children with absence seizures have a close relative who has seizures. **may be genetic While most children outgrow absence seizures, some: -Must take anti-seizure medications throughout life to prevent seizures -Eventually have full convulsions, such as generalized tonic-clonic seizures Other complications can include: -Learning difficulties -Behavior problems -Social isolation

Risk factors for GTCS

Risk factors for Generalized Tonic-Clonic Seizures include: A family history of seizure disorders Any injury to the brain from trauma, a stroke, previous infection and other causes Sleep deprivation Medical problems that affect electrolyte balance Illicit drug use Heavy alcohol use Risk for Injury r/t- -Falling. If you fall during a seizure, you can injure your head or break a bone. -Drowning. If you have a seizure while swimming or bathing, you're at risk of accidental drowning. -Car accidents. A seizure that causes either loss of awareness or control can be dangerous if you're driving a car or operating other equipment. -Pregnancy complications. Seizures during pregnancy pose dangers to both mother and baby, and certain anti-epileptic medications increase the risk of birth defects. -Emotional health issues. People with seizures are more likely to have psychological problems, such as depression and anxiety. Problems may be a result of difficulties dealing with the condition itself as well as medication side effects.

Concussion - FOCAL INJURY -Instant or delayed loss of consciousness as a result of blunt force. (sports injury) or fall -Caused by bruising of the brain -Direct blow-*Coup injury* -Indirect blow-reverberation is *counter coup* on opposite side. (may have both) -Individual may exhibit many types of level of consciousness

SHORT ANSWER ON EXAM: What are the s/s to educate pt going home with concussion & what action should they take? If patient loses consciousness must be seen in ER- CT scan Instruct patents to report any N&V Confusion, worsening ha, vision changes, dizziness, drainage from eyes or nose or seizures -call 911

How to keep patients safe during a seizure?

Seizure precautions: side rails up side lying position seizure pads against side rails pillow under head suction available bed in low position curtain for privacy Do not forget -Airway, Breathing - may need to provide Oxygen, suction, airway management- IV line- Antiseizure meds- benzos and phenobarbital.

What are urinalysis and urine specific gravity used to assess?

To assess kidneys' ability to concentrate urine. Dipstick and 24-hour urine tests for proteinuria and micro-albuminuria are used to detect abnormal filtering of albumin in the glomeruli.

What is TURP?

Transurethral resection of the prostate (TURP) is a surgery used to treat urinary problems due to an enlarged prostate.

Incontinence interventions

Treat reversible causes Urinary habit training (if incontinence not reversible) Intermittent urinary catheterization NOT Foley catheter Various devices Final strategy—containment of urine, protection of patient's skin with barrier cream, etc.

Pre-ictal phase - Auras

Trigger; When you consider that the term ictus means seizure, it makes sense that pre-ictal refers to a period before a seizure occurs. Seattle Veterinary Specialists breaks the pre-ictal phase into two components: the prodrome and the aura In an aura, alterations in activity, emotions, hearing, smell, taste, visual perception are involved. AURAS Auras are actually a small partial seizure that is often followed by a larger event. They usually come a few seconds to a few minutes before the actual seizure. It's the beginning of the seizure and is seen mostly in partial seizures. The feelings of the aura are often vague and many patients are unable to describe their features.

Define type of seizure: unclassified

Unclassified: occur for no reason -primary: not associated with any identifiable brain lesion nor other cause; idiopathic -secondary: result from underlying brain lesion (tumor/trauma). May be caused by: metabolic disorders, electrolyte imbalance, high fever, stroke, head injury, substance abuse, and heart disease.

Describe BUN.

Urea is formed in liver as a by-product of protein metabolism and is eliminated entirely by the kidneys; thus, BUN is r/t the GFR, but unlike creatinine, is also influenced by protein intake, GI bleeding, and hydration status.

Lithotripsy

Uses sound, laser, or dry shock wave energy to break stones into small fragments Patient undergoes conscious sedation Topical anesthetic cream applied to skin site Continuous monitoring by ECG

Ictal phase - know how to classify seizure, know nursing assessments and interventions

What happened; The seizure itself is the ictus. There are two major types of seizure: partial and generalized. What happens to the person during the seizure depends on where in the brain the disruption of neural activity occurs. Following a seizure, the person enters into the postictal state. Drowsiness and confusion are commonly experienced during this phase. ICTAL PHASE The middle of a seizure is called the ictal phase. It's the period of time from the first symptoms (including an aura) to the end of the seizure activity, which correlates with the electrical seizure activity in the brain. Sometimes, the visible symptoms last longer than the seizure activity on an EEG. That's because some of the visible symptoms may be after-effects of a seizure or not related to seizure activity at all.

What are risk factors for UTI's in women? Men? Both?

Women: sexual intercourse, pregnancy, diaphragm use, spermicides, DM, hx of UTI, and delayed post-coital voiding Men: lack of circumcision, prostatic hypertrophy, AIDS, homosexual activity Both: Obstruction of urinary flow: congenital abnormalities, renal calculi, ureteral occlusion Vesicoureteral reflux Residual urine in bladder: neurogenic bladder, urethral stricture Instrumentation of the urinary tract: indwelling catheter, intermittent catheterization, urethral dilation, and cystoscopy

An elderly female client with an indwelling urinary catheter is exhibiting confusion and is suspected of having a urinary tract infection. The nurse should collect a urine specimen for culture and sensitivity by: a. Disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container. b. Wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle. c. Draining urine from the drainage bag into a sterile container. d. Clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine.

b. Wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle.

Renal Calculi: The nurse is ware that the following is an appropriate nursing diagnosis for a client with renal calculi? a. Ineffective tissue perfusion b. Functional urinary incontinence c. Risk for infection d. Decreased cardiac output

c. Risk for infection Due to urine blockage/back-up

Acute Kidney Failure: A female adult client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)? a. Blood urea nitrogen (BUN) level of 22 mg/dl b. Serum creatinine level of 1.2 mg/dl c. Serum creatinine level of 1.2 mg/dl d. Urine output of 400 ml/24 hours

d. Urine output of 400 ml/24 hours Decreased urine output may be r/t fluid volume loss

Prostate problem s/s:

frequency, urgency, nocturia hematuria, increase infections, decrease urinary stream, and increase residual urine