1538 exam 2

left sided stroke

impaired left/right discrimination

left sided stroke

impaired language comprehension

jugular vein distention

a nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. which finding requires further action?

embolic stroke

a piece of thrombus or other matter traveling through small vessels in the brain becomes lodged in a vessel seen more in younger patients and when awake / active many come from thrombus in left chambers of the heart - atrial fibrillation - bacterial endocarditis - recent MI - rheumatic heart disease - ventricular aneurysm sudden onset with immediate deficits

amyotrophic lateral sclerosis

a progressive, degenerative disease involving lower motor neurons

stroke

5th leading cause of death in the US more common in men highest incidence in over 65 age group the leading cause of serious long term disability in the US financial impact can be profound - CT without contrast because contrast can mask the bleed

Face Arms Speech Time

FAST

Face: facial drooping Arm: arm weakness Speech: slurred speech Time: call 911 immediately if any above symptoms

FAST

fluctuating hearing loss

a form of sensorineural hearing loss that varies over time.

myasthenia gravis

a neuromuscular disorder that progresses very rapidly and has profound fatigue and muscle weakness

ischemic stroke

accounts for about 87% of all strokes

sensorineural hearing loss

affects the inner ear and involves the cochlea and 8th cranial nerve

in spinal shock

all reflexes are absent and the extremities are flaccid.

grief - psychological

anger depression lashing out

grief - role of the nurse

assess grief

grief - role of the nurse

assisting survivor

left sided stroke

cautious

anopia

defect in visual fields

spinal shock occurs

during the period immediately following a spinal cord injury

unknown seizure

epilepsy spasms

seizure causes

fever infection lack of sleep changes in sodium (low) meds (narcan, rimazecon) head injury (bleeding on the brain) brain tumor drugs allergic reaction drug/alcohol withdrawal

classification of seizures

focal generalized unknown provoked

stroke risk factors

hypertension heart disease (a. fib, heart failure, valve disease, congenital defects) DM sleep apnea (increases BP and CO2 in blood) high cholesterol smoking sickle cell disease substance abuse living in the SE US african american heritage

right sided stroke

impaired judgment and time concepts

right sided stroke

impaired judgment and time concepts impulsive and safety concerns left sided neglect left sided hemiplegia short attention span spatial perceptual deficits tends to deny or minimize problems neglect syndrome more common (unaware of left side and neglects that side or believes everything is ok)

left sided stroke

impaired speech

right sided stroke

impulsive safety concerns

grief process

individualized - circumstances - age - history

stroke nursing diagnoses

ineffective tissue perfusion: cerebral impaired physical mobility self care deficit impaired verbal communication impaired urinary elimination risk for constipation impaired swallowing

a positive kernig's sign

is a manifestation of meningeal irritation.

homonymous hemianopia

loss of half of visual field on same side in both eyes

post concussion syndrome

manifestations of classic concussion symptoms that persist days, weeks, or even months related to amount of neuronal damage emotional distress motivational issues cognitive factors (difficulty focusing, dizziness, HA)

TIA

mini stroke

grief

multifaceted reaction to loss whether real or perceived and how this impacts health. - psychological - biological - behavioral

fibrinolytic therapy

must be given within 3 hours of symptom onset

right sided stroke

neglect syndrome more common (unaware of left side and neglects that side or believes everything is ok)

TIA

neurological manifestations vary according to location brief period of ischemia causing neurological deficits lasting less than 24 hours - contralateral weakness or numbness of leg, hand, forearm, corner of mouth - aphasia - visual disturbances - may be warning sign for ischemic stroke - causes - inflammatory artery disorders - sickle cell disease - atherosclerotic changes in cerebral vessels - thrombosis - emboli

fibrinolytic therapy

never given to patients with hemorrhagic stroke

grief process

no correct way to grieve

functional hearing loss

no organic lesion is found

grief process

no timetable

concussion

observation of patients after head trauma: report immediately - observe for any changes in LOC - difficulty in awakening, lethargy, dizziness, confusion, irritability, anxiety - difficulty in speaking or movement - severe headache - vomiting pt should be aroused and assessed frequently with hourly LOC checks

generalized seizure

occur and engage bilaterally

focal seizure

originates in one hemisphere

concussion

patient may be admitted or sent home

left sided stroke

slow performance

right sided stroke

spatial-perceptual deficits

stom

stomach upset anxiety attack weakness headaches

seizure disorder

sudden excessive discharge from cerebral neurons

right sided stroke

tends to deny or minimize problems

kernig's sign

the nurse can elicit this sign by placing the client in a supine position and flexing the leg at the hip and knee. pain or resistance when the knee is straightened suggests meningeal irritation.

increased intracranial pressure

the nurse is assessing a client with a head injury. on admission, the pupils were equal; now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. what would this change in neurologic status suggest to the nurse?

grief - role of the nurse

utilize interdisciplinary team

lichtheim's sign

is the inability to speak associated with subcortical aphasia.

cumulative loss

lack of resolve

thrombotic stroke

large vessel occlusion by a thrombus - commonly caused by atherosclerotic plaque that triggers the clotting sequence with platelet adherence thus forming a thrombus - usually only affects 1 region of the brain that was supplied by a single artery - many times begins with TIA then worsens over 1-3 days resulting in completed stroke with edematous and necrotic brain tissue - seen more in older patients and when resting

right sided stroke

left sided hemiplegia

you should review this info with your healthcare provider at every admission.

a 35 year old client diagnosed with multiple sclerosis three years ago presents the nurse with an advance directive refusing intubation, mechanical ventilation, and tube feedings. how should the nurse respond?

absence of reflexes along with flaccid extremities

a client with quadriplegia is in spinal shock. what finding should the nurse expect?

the decision is whether you want to honor their wishes concerning organ donation.

a coordinator from an organ procurement agency is leading a meeting with a physician, a nurse, and the parent of a client with confirmed brain death. the client's driver's license indicates that they are an organ donor. after the meeting, the client's parent states, i just can't make the decision to let him die. which response by the nurse is best?

MS

a debilitating disease involving the myelin sheath

kernig's sign

a nurse is assessing a client with meningitis. the nurse places the client in a supine position and flexes the client's leg at the hip and knee. the nurse notes resistance when straightening the knee and the client reports pain. the nurse should document what neurologic sign as positive?

grief - behavioral

anger and outbursts

conductive hearing loss

audiometry confirms a client's chronic progressive hearing loss. further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. this type of hearing loss is called....

left sided stroke

aware of deficits

left sided stroke

aware of deficits depression, anxiety impaired language comprehension impaired left/right discrimination impaired speech right sided hemiplegia slow performance cautious

hemorrhagic stroke

cerebral blood vessel ruptures - many times caused by sustained elevate4d BP or aneurysm usually occur suddenly and when patient is active manifestations depend on location - vomiting - headache - seizures - hemiplegia - loss of consciousness

ischemic stroke

classified as transient, thrombotic, or embolic

fibrinolytic therapy

converts plasminogen to plasmin resulting in fibrinolysis of clot

biolo

grief - biological

babinski's reflex

is an indicator of corticospinal damage.

the knee-chest position

is necessary to make the procedure of lumbar puncture safer and easier to perform.

provoked seizure

related to acute, reversible condition

conductive hearing loss

results from interference with the conduction of sound waves from the tympanic membrane to the inner ear. the stapes must move freely for sound to be transmitted. bone tissue overgrowth causes the stapes to become fixed or immobile in the oval window, preventing sound transmission.

the grief experience

unique influences are: culture, belief system, faith, life experiences affect: physical, psychological, social, spiritual

huntington's chorea

a chronic disease with a disturbance in nerve transmission

ensure that oxygen is flowing at 5 liters per minute by nasal cannula. check the client's pulse oximetry reading every 1 hour.

a client is stabilized in the emergency department and moved to the neurologic intensive care unit with a diagnosis of spinal cord injury at level C4-C5. the nurse is working with an experienced unlicensed assistive personnel. which items can the nurse delegate to the UAP? select all that apply.

it is a chronic disease in which there is a disturbance in nerve transmission to the muscle, resulting in fatigue and muscle weakness.

a client with a new diagnosis of myasthenia gravis asks, what is happening to me? what would be the most appropriate response by the nurse?

death anxiety

defenses withdrawal from patients and families

stroke clinical manifestations

depend on cerebral artery involved women may report nontraditional manifestations - disorientation, confusion, changes in LOC most common - weakness of face, arm, and sometimes leg other common - numbness on one side, loss of vision, speech difficulties, sudden severe HA, difficulties with balance

left sided stroke

depression, anxiety

grief process

different for all

post concussion syndrome symptoms

disabling difficulties may become evident after return to job or school may benefit from referral to specialist must be advised to avoid activities with potential for high risk for repeated concussion, such as contact sports because repeat concussion may cause autoregulatory dysfunction and progressive cerebral edema.

febrile seizure

does not cause brain damage

babinski's reflex

dorsiflexion of the great toe with extension fanning of the other toes is an abnormal reflex elicited by firmly stroking the lateral aspect of the feet with a blunt object.

febrile seizure

fever induced seizure caused from rapid increase in temp but does not cause brain damage

brudzinski's sign

flexion of the hips and knees in response to positive flexion of the neck that also signals meningeal irritation.

right sided stroke

left sided neglect

left sided stroke

right sided hemiplegia

hemorrhagic stroke

ruptured blood vessel

right sided stroke

short attention span

JVD

signals vascular fluid overload

the client can be pronounced dead

because the client meets the criteria for brain death.

stroke treatment

begin with complete history and careful physical assessment including time of onset of symptoms CT w/o contrast to determine type of stroke prevention - antiplatelet therapy acute stroke - ischemic stroke - anticoagulant to prevent further formation of thrombus - coumadin, heparin, lovenox - fibrinolytic therapy - converts plasminogen to plasmin resulting in fibrinolysis of clot - given within 3 hours of onset of symptoms - anticoagulant and fibrinolytic agents never given to patients with hemorrhagic stroke

subarachnoid hemorrhage

bleeding into spaces around the brain

intracerebral hemorrhage

bleeding within the brain

hemianopia

blindness in half of visual field in one or both eyes

ischemic stroke

blood flow blocked by blockage or stenosis of a cerebral artery

ischemic stroke

blood supply is interrupted by thrombus, embolus, or stenosis.

although the required position may not be comfortable, it will make the procedure safer and easier to perform.

a client preparing to undergo a lumbar puncture states they don't think they will be able to get comfortable with their knees drawn up to the abdomen and the chin touching their chest. the client asks if they can lie on their left side. which statement is the best response by the nurse?