Adult Health Exam III
A patient with a history of depression and anxiety comes in with a complaint of migraines. She says "My friend takes sumatriptan for hers and I want that since it works so well." How do you respond?
"When talking to your provider, make sure to tell him if you take any SSRI's or St John's Wort for your depression as it will interact with sumatriptan and may cause serotonin syndrome"
What are some aneurysm precautions?
1) strict HOB 30 degrees 2) non-stimulating, non-stressful environment 3) avoid all activity that may increase ICP or BP like valsalva maneuver, acute rotation or flexion of the head and neck
A patient in the hospital begins to experience a cluster headache. Because you are an amazing nurse, you know that the first intervention you would give is?
100% oxygen via facemask x15 min
A client had a cast applied to a fractured limb, and the healthcare provider has ordered frequent neurovascular checks. Which assessment should the nurse perform? (Select all that apply.) A) Paresthesia B) Pain C) Position D) Color E) Temperature
A, B, D, E When conducting a neurovascular assessment, the 5 Ps should be evaluated. This includes pain, pallor, pulse, paresthesia, and paralysis. Position is not part of the neurovascular assessment.
This drug can treat trigeminal neuralgia and seizures, how?
Carbamazepine treats both of these conditions by decreasing neuron firing activity
A 7-year-old male patient is being evaluated for seizures. While in the child's room talking with the child's parents, you notice that the child appears to be daydreaming. You time this event to be 10 seconds. After 10 seconds, the child appropriately responds and doesn't recall the event. This is known as what type of seizure? A) Focal Impaired Awareness (complex partial) B) Atonic C) Tonic-clonic D) Absence
D) Absence
How do you treat septic arthritis?
Immobilization of joint, pain relief, and antibiotics
What is the priority patient education around osteomyelitis treatment?
Long term IV antibiotic therapy, mobility limitations
How does septic arthritis occur?
Penetrating injury, animal bite, another source of infection that travels through bloodstream
The patient who had a confirmed TIA had the doctor explain what that diagnosis means and still looks confused. When the doctor leaves they turn to you and say "I don't understand, does that mean I had a stroke?" What do you say to them?
You did not have a stroke. A TIA is a temporary neurologic deficit caused by a temporary impairment to blood flow. While this wasn't a stroke, it's important to treat this as it can be an indicator to future strokes.
hemianopsia
blindness in half the visual field
What are the parameters for TPA?
-3 hour window since beginning of symptoms -ischemic stroke not hemorrhagic -no blood systolic pressure >185, no diastolic >110 -no recent surgery -no platelet count below 100,000 -can't be on blood thinners
What can we teach Sarah to help prevent any complications of osteoporsis?
-balanced diet high in calcium and vitamin D -use of calcium supplements to ensure adequate calcium intake; take in divided doses with vitamin C -regular weight-bearing exercises like walking -weight training to stimulate bone mineral density
Patient education back pain what NOT to do
-lean forward without bending knees -lift anything above level of elbows -stand in one position for prolonged times -sleep on abdominal or on back or side with legs out straight -exercise without consulting PCP if having severe pain
What are some clinical manifestations of a stroke?
-numbness or weakness of the face, arm or leg, especially on one side of the body -sudden confusion or AMS -trouble speaking or understanding speech -visual disturbances -difficulty walking, dizziness, or loss of balance or coordination -severe headache
A patient comes in with what is determined to be an ischemic stroke. During this acute phase, you the nurse are monitoring what?
-ongoing, frequent monitoring of all systems, including vital signs, neuro, LOC, motor symptoms, speech, and eye movements
Amputation care
-proper positioning of limb -turn the patient frequently -assistive devices to help with mobility -ROM exercises -muscle-strengthening -"pre-prosthetic care"
Patient Education back pain what to do
-sleep in a side-lying position with knees and hip bent -sleep on back with a lift under knees and legs -prevent lower back pain from straining forward by placing a foot on a step or stool during prolonged standing -maintain appropriate body weight -back strengthening exercises -avoid long periods in one position =bend knees, tighten abd muscles during lifting -avoid twisting/jerking motions -local heat/cold -lumbar roll/pillows
What medications are you expecting to be ordered for your patient with Trigeminal Neuralgia and why?
1) Carbamazepine to help decrease neuron firing 2) Gabapentin and Baclofen to lower transmission of pain signals
What medications are you expecting to be ordered for your patient with Bell's Palsy and why?
1) Prednisone, a corticosteroid to help with the swelling caused by this condition 2) Acyclovir, a antiviral medication to treat the herpes 3) Analgesics for pain from the condition
What medications do you expect to be ordered for your patient with multiple sclerosis and why?
1) methylprednisolone to help with the symptoms of MS 2) gabapentin and baclofen to lower transmission of pain signals 3) oxybutinin: to help with urinary spasticity/incontinence
When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include? A) "You should call the doctor if pain or herpes lesions occur near the ear." B) "Treatment of herpes with antiviral agents will prevent development of Bell's palsy." C) "Medications to treat Bell's palsy work only if started before paralysis onset." D) "You may be able to prevent Bell's palsy by doing facial exercises regularly."
A) "You should call the doctor if pain or herpes lesions occur near the ear." Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.
The client diagnosed with Guillain-Barré syndrome asks the nurse, "Will I ever get back to normal? I am so tired of being sick." Which statement is the best response by the nurse? A) "You should make a full recovery within a few months to a year." B) "Most clients with this syndrome have some type of residual disability." C) "This is something you should discuss with the health-care team." D) "The rehabilitation is short and you should be fully recovered within a month."
A) "You should make a full recovery within a few months to a year."
Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barré syndrome? A) Assess deep tendon reflexes. B) Complete a Glasgow Coma Scale. C) Check for Babinski's reflex. D) Take the client's vital signs.
A) Assess deep tendon reflexes Hyporeflexia of the lower extremities is the classic clinical manifestation of this syndrome. Therefore, assessing deep tendon reflexes is appropriate.
. You're assessing a patient who recently experienced a focal type seizure (partial seizure). As the nurse, you know that which statement by the patient indicates the patient may have experienced a focal impaired awareness (complex partial) seizure? A) "My friend reported that during the seizure I was staring off and rubbing my hands together, but I don't remember doing this." B) "I remember having vision changes, but it didn't last long." C) "I woke up on the floor with my mouth bleeding." D) "After the seizure I was very sleepy, and I had a headache for several hours."
A) My friend reported that during the seizure I was staring off and rubbing my hands together, but I don't remember doing this
Your patient had a femoral fracture and has skin traction. Which of the following can you perform in caring for this patient? A) Neurovascular assessments every 2 hours B) Adjusting the 60 lb. weight every 2 hours C) Remove boot every shift for at least 15 minutes. D) Have the patient turn every 2 hours
A) Neurovascular assessments every 2 hours NEVER touch traction, don't touch the boot, don't turn the pt and mess with the traction!!!
A 32-year-old patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? A) Notify the health care provider. B) Assess the incision for redness. C) Reposition the left leg on pillows. D) Check the patients blood pressure.
A) Notify the health care provider Severe pain in casted leg after getting pain meds, faintly palpable pulse in the foot, and cool to the touch are all signs of compartment syndrome which is a medical emergency
This prototype drug is used primarily for Generalized Seizures A) Phenytoin B) Carbamazepine C) Morphine Sulfate D) Gabapentin
A) Penytoin
The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by A) Taking medications on time to maintain therapeutic blood levels B) Doing all chores early in the day while less fatigued C) Doing muscle-strengthening exercises D) Eating large, well-balanced meals
A) Taking medications on time to maintain therapeutic blood levels Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress
Which clinical manifestation would be required to confirm the diagnosis of Parkinson disease? A) Tremors at rest and bradykinesia B) Bradykinesia only C) Rigidity only D) Tremor at rest and flaccidity
A) Tremors at rest and bradykinesia A diagnosis of Parkinson disease requires the presence of two of the three cardinal manifestations: tremor, rigidity, and bradykinesia. Tremors at rest and bradykinesia are two of the cardinal signs. Bradykinesia alone would not be diagnostic. Tremors at rest are a cardinal sign, but flaccidity is not. Rigidity is a cardinal sign, but rigidity alone is not diagnostic.
A client who was treated for a long bone fracture suddenly has a respiratory rate of 28 breaths/ min with an oxygen saturation of 86% on room air. The client is confused and restless, and suddenly has petechiae noted on the neck and conjunctiva. Which collaborative intervention is appropriate? A) Applying oxygen and continuing to assess respiratory status B) Intubating the client immediately C) Immediately immobilizing the pelvic area D) Administering corticosteroids as ordered
A) applying oxygen and continuing to assess resp status This client is showing signs of fat embolism syndrome (FES). Priority treatment is to administer oxygen and continue to assess respiratory status to try to prevent intubation. Approximately 50% of the clients will have to be intubated eventually, but the goal is to prevent this invasive treatment. Corticosteroids and immobilization of the injured area may reduce the risk of FES but will not treat the syndrome once it occurs.
A patient is taking Phenytoin for treatment of seizures. Which statement by the patient requires you to re-educate the patient about this medication? A) "Every morning I take this medication with a full glass of milk with my breakfast." B) "I know it is important to have my drug levels checked regularly." C) "I will report a skin rash immediately to my doctor." D) "This medication can lower my body's ability to clot and fight infection."
A) every morning I take this medication with a full glass of milk with my breakfast NEVER TAKE PHENYTOIN WITH MILK
During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should: A) examine the mouth and teeth thoroughly B) have the patient clench and relax the jaw and eyes C) identify trigger zones by lightly touching the affected side D) gently palpate the face to compare skin temperature bilaterally.
A) examine the mouth and teeth thoroughly
When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about A) triggers that lead to facial pain B) visual problems caused by ptosis C) poor appetite caused by a loss of taste D) decreased sensation on the affected side.
A) triggers that lead to facial pain
A client is brought to the ER and is determined to be suffering a stroke. The MD orders tPA, which of the following would make you question the provider's order? (SATA) A) Pt has a hx of liver dysfunction. B) Recent VS include HR 104, BP: 194/112, RR 20, Temp 37.8degC C) platelet count 95,000/mm^3 D) Pt is 19 years of age
A, B, C A. Pt has a hx of liver dysfunction. B. Recent VS include HR 104, BP: 194/112, RR 20, Temp 37.8degC C. platelet count 95,000/mm^3tPA is contraindicated in pt's who have liver disorders, BP >185/110, and platelet counts <100,000mm^3. Cannot give to a pt who has had a recent surgery (14 days), hemorrhagic stroke.
A client fell off a ladder and the healthcare provider suspects a fracture of the right wrist. Which manifestation should the nurse anticipate observing in the client? (Select all that apply.) A) Crepitus B) Visible deformity C) Pain D) Cyanosis of nail beds E) Absence of radial pulse
A, B, C D+E would be noticed later on if it continues to go untreated and compartment syndrome occurs
Which actions by the nurse demonstrate an understanding of caring for a client in traction? Select all that apply. A) Placing a trapeze on the bed B) Ensuring that the weights are hanging freely C) Assessing the client's alignment in the bed D) Removing skeletal traction to turn and reposition the client E) Frequently assessing pain level
A, B, C, E Trapeze helps patient move higher up in bed w/o messing with traction. Weights should be hanging freely not touching any surface. Correct alignment in bed will help with pain.
The nurse is assessing an older adult client. Which finding should cause the nurse to suspect the client has Parkinson disease (PD)? (Select all that apply.) A) The client has hand tremors at rest. B) The client does not remember what he ate for breakfast. C) The client's blood pressure increases when the client stands up. D) The client has a slurred speech. E) The client's facial expression shows no emotion.
A, B, D, E PD causes slowed movements, including slurred speech. Tremors at rest are very common in PD and easy to identify. Tremors may occur in the hands, face, neck, lips, tongue, and jaw. PD causes a frozen, mask-like expression (lack of affect). The client will not have an expression that is consistent with the emotions the client is feeling. Memory loss occurs in Parkinson disease because of the loss of neurons and other changes in the brain. The client may develop dementia. Postural hypotension, not hypertension, is a common manifestation in clients with PD. This is caused by damage to the autonomic nervous system.
The primary health care provider diagnoses that a patient has a cluster headache. Which statements made by the patient support the health care provider's diagnosis? Select all that apply. A) "My cheeks also ache during the headache." B) "I feel like my limbs are moving during the headache." C) "I don't feel like sitting in one place during the headache." D) "My skin appears pale during the headache." E) "I have a strong desire to eat ice cream and chocolates during the headache."
A, C, D cluster headache is manifested by pain in the cheeks, gums, nose, and forehead. Cluster headache is also associated with restlessness and pallor (skin paleness). Feelings of limb movement and food cravings are clinical manifestations of migraine headache.
The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess? Select all that apply. A) Muscle flaccidity B) Lethargy C) Dysmetria D) Fatigue E) Dysphagia
A, C, D, E A) Muscle flaccidity is a hallmark symptom of MS. C) Dysmetria is the inability to control muscular action characterized by overestimating or under estimating range of movement. D) Fatigue is a symptom of MS. E) Dysphagia, or difficulty swallowing, is associated with MS.
Your patient is experiencing pain, and increased pressure in his lower leg after being treated for a fracture. It is not relieved by opioids, and you cannot palpate a pedal pulse. Which of the following interventions may be done? SATA. A) Removal of cast B) Elevation the leg C) Ice the leg D) Fasciotomy E) Amputation
A, D, E Symptoms indicate compartment syndrome, which you would not use RICE to treat. Fasciotomy can help relieve pressure inside the leg, amputation is a last resort option, removal of the cast is first line
True or False for Status Epilepticus A-It is not an emergency B-It can involve any type of seizure C-The brain is using more energy than supplied
A- False, status epilepticus is a medical emergency B- True, any type of seizure can develop into this C- True, this happens when the brain uses more energy than supplied for too long
Which statement by the client supports the diagnosis of Guillain-Barré syndrome? A) "I just returned from a short trip to Japan." B) "I had a really bad cold just a few weeks ago." C) "I think one of the people I work with had this." D) "I have been taking some herbs for more than a year."
B) "I had a really bad cold just a few weeks ago." This syndrome is usually preceded by a respiratory or gastrointestinal infection one (1) to four (4) weeks prior to the onset of neurological deficits. 1. Visiting a foreign country is not a risk factor for contracting this syndrome. 3. This syndrome is not a contagious or a communicable disease. 4. Taking herbs is not a risk factor for developing Guillain-Barré syndrome
Which action will the nurse take in order to evaluate the effectiveness of Bucks traction for a 62-year-old patient who has an intracapsular fracture of the right femur? A) Check peripheral pulses. B) Ask about hip pain level. C)Assess for hip contractures. D) Monitor for hip dislocation.
B) Ask about hip pain level Bucks traction keeps the leg immobilized and reduces painful muscle spasm.
You're developing discharge instructions to the parents of a child who experiences atonic seizures. What information below is important to include in the teaching? A) "This type of seizure is hard to detect because the child may appear like he or she is daydreaming." B) "Be sure your child wears a helmet daily." C) "It is common for the child to feel extremely tired after experiencing this type of seizure." D) "Avoid high fat and low carbohydrate diets."
B) Be sure your child wears a helmet daily This type of seizure leads to a sudden loss of muscle tone. The patient will go limp and fall, which when this happens the head is usually the first part of the body to hit the floor or an object nearby. A) is a characteristic of an absence seizure. C) is a characteristic of a tonic-clonic seizure during the post ictus stage. D) is wrong because some patients benefit from this type of diet known as the ketogenic diet.
The health-care provider scheduled a lumbar puncture for a client admitted with rule-out Guillain-Barré syndrome. Which pre procedure intervention has priority? A) Keep the client NPO. B) Instruct the client to void. C) Place in the lithotomy position. D) Assess the client's pedal pulse.
B) Instruct the patient to void The client should void prior to this procedure to help prevent accidental puncture of the bladder during the procedure.
You walk into the patient room and find the UAP helping the patient with a new cast get ready for a shower. What action would need immediate intervention? A) The UAP is moving the cast with the palm of her hands B) The UAP is wrapping the cast in plastic to protect it from the water C) Asking if the patient has any pain around their cast D) Looking for any swelling
B) Wrapping the cast in plastic Putting plastic on the cast hinders the cast for hardening
When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of trigeminal neuralgia, an appropriate action to include is: A) teach facial and jaw relaxation techniques B) assess intake and output and dietary intake C) apply ice packs for no more than 20 minutes D) spend time at the bedside talking with the patient.
B) assess intake and output and dietary intake
the nurse is caring for a client who begins to experience seizure activity while in bed. which action by the nurse is contraindicated? A) loosening restrictive clothing B) restraining the clients limbs C) removing the pillow and raising padded side rails D) positioning the client to the side, if possible, with the head flexed forward
B) restraining the clients limbs
A client with Parkinson disease (PD) is prescribed an Benztropine to treat tremors and rigidity. The nurse should teach the client about which adverse effect they may experience from this medication? (Select all that apply.) A) Drooling B) Dry mouth C) Rigidity D) Loss of perspiration E) Tremors
B, D Anticholinergic medications can cause a decrease in salivation, causing dry mouth. This medication decreases tremors and reduces rigidity by blocking acetylcholine. The client taking this medication will have problems with temperature control because the client will not be able to perspire to cool off.
The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two(2) times in the month. Which question is most important for the nurse to ask the client? A) "Have you experienced any difficulty with your menstrual cycle?" B) "Have you noticed a rash across the bridge of your nose?" C) "Do you get tired easily and sometimes have problems swallowing?" D) "Are you taking birth control pills to prevent conception?"
C) "Do you get tired easily and sometimes have problems swallowing?" These are clinical manifestation of MS and can go un diagnosed for years because of the remitting-relapsing nature of the disease. Fatigue and difficulty swallowing are other symptoms of MS.
As a nursing student, you are assigned a patient with skeletal traction. You walk into your patient's room and they say "This traction is killing me, it's so painful! Can you please just remove it for like 10 minutes?" How do you reply? A) "Sure, but let me go get my nurse first since I'm only a student." B) "I can, but I need to get your blood pressure first to make sure you won't have orthostatic hypotension." C) "I'm sorry, we can't remove it unless there's an emergency." D) "The traction needs to fall off on its own. Within 48 hours, your pain should be relieved."
C) "I'm sorry, we can't remove it unless there's an emergency" NEVER TAKE OFF TRACTION!!!!
The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications?A) There will be fewer side effects with this combination than with carbidopa alone. B) Dopamine requires the presence of both of these medications to work. C) Carbidopa makes more levodopa available to the brain. D) Carbidopa crosses the blood-brain barrier to treat Parkinson's disease.
C) Carbidopa makes more levodopa available to the brain
Your patient has a history of epilepsy. While helping the patient to the restroom, the patient reports having this feeling of déjà vu and seeing spots in their visual field. Your next nursing action is to?* A) Continue assisting the patient to the restroom and let them sit down. B) Initiate the emergency response system. C) Lay the patient down on their side with a pillow underneath the head. D) Assess the patient's medication history.
C) Lay the patient down on their side with a pillow underneath the head
Which complaint made by the patient indicates that the individual may be suffering from a cluster headache? A) "The pain is constant." B) "The pain is followed by nausea." C) "The pain disturbs my sleep at night." D) "The pain lasts for longer than eight hours.
C) The pain disturbs my sleep at night Cluster headaches usually occur at night and causes sleep disturbances. Therefore, the patient's complaint about sleep-disturbing pain is a sign of a cluster headache. Constant pain is a characteristic of tension-type headaches. Migraine headaches are associated with nausea and vomiting; they usually exist for 4 to 72 hours.
Your patient is 2 hours post-op from a cast placement on the right leg. The patient has family in the room. Which action by the significant other requires you to re-educate the patient and family about cast care? A) Checking the color and temperature of the right foot. B) Elevating the cast above heart level with pillows. C) Gently using the fingertips of the hands to move the cast every 2 hours to help with drying. D) Using a hair dryer on the cool setting to help with drying and itching.
C) gently using the fingertips of the hands to move the cast every 2 hours to help with drying fingertips will cause dent formation, which can lead to skin ulcer formation overtime.
When a patient is experiencing a cluster headache, the nurse will plan to assess for A) nuchal rigidity. B) projectile vomiting. C) unilateral eyelid swelling. D) throbbing, bilateral facial pain.
C) unilateral eyelid swelling Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increases in intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.
What assessments is the nurse performing while the patient has a hemorrhagic stroke?
Complete and ongoing neuro assessment, monitoring resp status and oxygenation, monitoring ICP labs
How can we prevent a hemorrhagic stroke from occuring?
Control the patient's hypertension
How is septic arthritis diagnosed?
Culture of synovial fluid
The nurse observed a client with Parkinson disease frequently wiping their mouth with a handkerchief. After the nurse requested a prescription for Benztropine from the healthcare provider, the client asked, "I feel better, why do I need another medication?" Which response by the nurse is correct? A) "It helps dopamine work better." B) "It will make you feel better." C) "The healthcare provider thinks it will help your symptoms." D) "It will help reduce tremors and uncontrolled drooling."
D) "It will help reduce tremors and uncontrolled drooling." The client stated that they are feeling better. It is levodopa and not an anticholinergic that will make dopamine work better. Stating that the healthcare provider thinks it will help with the client's symptoms will be an incomplete answer. To give a complete response, the nurse would state that an anticholinergic reduces tremors and uncontrolled drooling.
Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barré syndrome? A) High risk for injury. B) Fear and anxiety. C) Altered nutrition. D) Ineffective breathing pattern.
D) Ineffective breathing pattern Guillain-Barré syndrome has ascending paralysis causing respiratory failure.Therefore, breathing pattern is priority.
While assessing your skeletal traction patient, you notice yellow drainage and swelling at the pin sites. As the nurse, you know that this could lead to.... A) Diabetes mellitus B) Avulsion fracture C) Turner syndrome D) Osteomyelitis
D) Osteomyelitis Infection=BAD
Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? A) An exaggerated startle reflex and memory changes. B) Cogwheel rigidity and inability to initiate voluntary movement. C) Sudden severe unilateral facial pain and inability to chew. D) Progressive ascending paralysis of the lower extremities and numbness.
D) Progressive ascending paralysis of the lower extremities and numbness C describes trigeminal neuralgia
The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis? A) Visual disturbances, including diplopia B) Ascending paralysis and loss of motor function C) Cogwheel rigidity and loss of coordination D) Progressive weakness that is worse at the days end
D) Progressive weakness that is worse at the days end The client with myasthenia develops progressive weakness that worsens during the day. Visual disturbances, including diplopia is incorrect because it refers to symptoms of multiple sclerosis. Ascending paralysis and loss of motor function is incorrect because it refers to symptoms of Guillain Barre syndrome. Cogwheel rigidity and loss of coordination is incorrect because it refers to Parkinsons disease.
A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? A) He didn't arrive within the time frame for that therapy B) Not every is eligible for this drug. Has he had surgery lately? C) You should discuss the treatment of your husband with your doctor D) The medication you are talking about dissolves clots and could cause more bleeding in your husband's head
D) The medication you are talking about dissolves clots and could cause more bleeding in your husband's head tPA dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic/embolic stroke the time frame would be important as well as a history of surgery. The nurse should answer the question as accurately as possible and then encourage the individual to talk with the primary care physician if he or she has further questions.
The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention? A) The client has scanning speech and diplopia. B) The client has dysarthria and scotomas. C) The client has muscle weakness and spasticity. D) The client has a congested cough and dysphagia.
D) The patient has a congested cough and dysphagia Dysphagia is a common problem of clients diagnosed with multiple sclerosis, and this places the client at risk for aspiration pneumonia. Some clients diagnosed with multiple sclerosis eventually become immobile and are at risk for pneumonia.
A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because: A) the patient has probably experienced an asymptomatic lacunar stroke B) the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours C) neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off D) the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease
D) The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease A TIA is a temporary focal loss of neurologic function caused by ischemia of an area of the brain, usually lasting only about 3 hours. TIAs may be due to microemboli from heart disease or carotid or cerebral thrombi and are a warning of progressive disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide prophylactic treatment if possible.
A 48-year-old patient with a comminuted fracture of the left femur has Bucks traction in place while waiting for surgery. To assess for pressure areas on the patients back and sacral area and to provide skin care, the nurse should: A) loosen the traction and help the patient turn onto the unaffected side. B) place a pillow between the patients legs and turn gently to each side. C) turn the patient partially to each side with the assistance of another nurse. D) have the patient lift the buttocks by bending and pushing with the right leg.
D) have the patient the buttocks by bending and pushing with the right leg NEVER TOUCH OR TAKE OFF TRACTION
What do you want to ask a patient with osteoporosis?
Do you use any corticosteroids, alcohol, smoking, and caffeine?
What is the best way to differentiate between an ischemic stroke and a hemorrhagic stroke? A. PET scan B) CBC C) CT scan with contrast D) MRI E) CT scan without contrast
E) CT scan without contrast
A patient is experiencing a temporal arthritis headache and begins to lose her vision. What intervention can you use to treat this?
High dose steroid treatment (prednisone) long term (2 years) to prevent vision loss; make sure to monitor ESR levels
The nurse is caring for a patient who is currently experiencing status epilepticus, which two drugs should she prepare to treat this?
IV lorazepam (ativan) and diazepam (valium), and they must be followed by long acting drugs
How do you relieve a patient's pain from osteomyelitis?
Immobilization of the affected extremity, elevation, handle with great care and gentleness, and administer prescribed analgesics
An 80 year old woman was admitted to the local community hospital following a motor vehicle crash. Her injuries include a left fractured hip and multiple contusions and lacerations. The nurse notes that preoperative Buck traction has been applied to the client's left leg with two weight of 5lbs (2.3kg) each. Is it appropriate to remove the traction as part of the skin assessment?
NO!!!! Traction is never removed or touched by the nurse. It is appropriate for the nurse to check all traction ropes and knots every shift for intactness
Nursing assessment priority with amputation
Neurovascular status and function of affected extremity or residual limb and of unaffected extremity
A 16-year-old boy presents to the hospital with an old sports injury that never got treatment. He has chills followed by a fever of 39.5ºC. His lower left leg has severe localized pain, +2 edema, is warm to the touch and has an opening with malodorous drainage coming out. His labs come back with an elevated WBC count. What is he most likely suffering from?
Osteomyelitis, an infection of the bone caused by an extension of soft tissue infection, direct bone contamination, or blood-borne spread from another site of infection (usually trauma)
64 year old Sarah comes into the ED with a tibia fracture after experiencing a fall. PMH shows that she is experiencing menopause and that she is experiencing more frequent fractures due to falls over the last couple of years. What is she most likely experiencing?
Osteoporosis, a condition where bone becomes porous, brittle, fragile, and breaks more easily under stress
What are some amputation complications to watch out for?
Postop hemorrhage, infection, skin breakdown
You are providing medication education to a patient with a new diagnosis of Myasthenia gravis. What do you tell her?
Pyridostigmine slows ACh breakdown which will help with the prevention of any symptoms. You may experience do diarrhea, excessive salivation and abd cramping. You will also receive some corticosteroids to help relieve you of symptoms. IVIG will help reverse any exacerbations of MG and lasts for a month.
A patient comes in with paralysis on one side of the face. PMH shows that the patient had herpes and the doctor rules out stroke. What do you tell the patient?
Reassure the patient that they haven't had a stroke. They have Bell's Palsy, a condition that causes one sided facial paralysis after being exposed to the herpes virus.
What are the major goals when treating backpain?
Relief of pain, improved physical mobility, use of back conversion techniques and proper body mechanics, improved self-esteem, and weight reduction
How can you improve the physical mobility of a patient with osteomyelitis?
Restricted activity, gentle ROM to joints above and below affected area, participation in ADLs within limitations, encourage adequate hydration and nutritional intake
A patient comes in with an acute, swollen painful joint and their bloodwork comes back with an elevated WBC. What would you be suspicious of?
Septic arthritis
A patient tells her nurse that she is currently taking phenytoin and carbamazepine for her seizures but she can't remember what side effects she may experience. What can you tell her?
She may experience some diplopia, drowsiness, ataxia, and mental slowing. Also make sure to stress how important it is that she takes these meds everyday.
Alendronate
Slows bone loss, helping to maintain strong bones and reduce risk of fractures. Give with lots of water at least 30 min before eating any food. May lower calcium lvls
You are about to admit a patient with a history of a stroke. What meds might you expect for them to be on?
Some kind of anticoagulant therapy, anti platelet therapy (aspirin, dipyridamole, aspirin, clopidogrel), the statins, and anti-HTN medications
A patient that experiences crippling migraines is telling her nurse about the meds she takes for them. She can't remember what it's called, but she knows that she is supposed to take it before the migraine even starts. What medication might she be talking about?
Sumatriptan, a serotonin receptor agonist. It causes vasoconstriction to help decrease inflammation and pain transmission. Tell the patient she may experience chest pain while on this med.
The nurse is caring for a client admitted with suspected myasthenia gravis. Which diagnostic test will likely be ordered, what medication will be used and what should you have on hand?
The ACh inhibitor test or the TENSILON test will be performed. IV edrophonium chloride is used during the test, and make sure to have atropine on hand to reverse its effects.
You are tasked with providing education to a patient with a new diagnosis of Bell's Palsy. What do you include?
Their condition will not allow them to close their eye on the affected side, so it is important to wear protection including dark glasses, artificial tears and covering the affected eye at night. Full recovery is expected but will take around 6 months.
As an amazing nurse, you know that when treating a patient with Guillain-Barre Syndrome, they will most likely receive what medication and when?
They will receive IVIG ideally before the three week mark to reverse any symptoms of the condition
When is an amputation indicated?
To relieve symptoms, improve function, and save the person's life
What are some complications of a hemorrhagic stroke?
Vasospasm, hydrocephalus, seizures, re-bleeding, hyponatremia
A patient who experienced a TIA is about to go to the operating room for a carotid endarterectomy. How do you explain this surgery to them?
While you are under anesthesia, the doctor will go in and remove the potential source of emboli from the carotid. We will watch you after for any complications like bleeding, hypotension, HTN, etc.
Stump wound care
elevate for the first 24 hours prevent contracture above amputation analgesics compression dressing discourage semi-fowlers position with client with above the knee amputation to prevent contractures of hip observe for bleeding
aphasia
inability to speak/understand speech
What are some complications of an ischemic stroke?
increased ICP, meningeal irritation, decreased cerebral blood flow, inadequate oxygen to the brain, pneumonia, UTI's, dysrhythmias, and complications of immobility
hemiplegia
paralysis of one side of the body
hemiparesis
weakness on one side of the body
