Medsurg 2 Unit 1-2
Right brain injury findings
-Left side weakness: Hemiplegia -Impairment in creativity: arts & music -Confused on date, time, place -Cannot recognize faces or the person's name -Loss of depth perception -Trouble staying on topic when talking -Can't see things on left side: LEFT SIDE NEGLECT: ignores left side of body -Trouble with maintaining proper grooming -Emotionally: not going to think things through...very impulsive -Poor ability to make decisions and assessing spatial elements...shapes -Denial about limitations -Not able to interpret nonverbal language or under- stand the hidden meaning of things -Very short attention span
normal urine specific gravity
1.005-1.030
Normal sodium levels
135-145 mEq/L
Normal PbtO2
20-35mmHg
Normal PaCO2
35-45 mmHg
Normal ICP
5-15 mmHg
Normal MAP
6/70 - less than 150
Normal CPP
60-100
A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure? A. Battle's sign B. Periorbital edema C. Dilated pupils D. Halo sign
C
A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain? (A. Occipital B. Temporal C. Frontal D. Limbic
C
A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect? A. Spasticity of the left foot B. Negative Babinski reflex C. Ocular hypertension D. Right-sided hemiplegia
D
A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching?
Darken the lights. Rationale: The nurse should instruct the client to lie down in a dark room to reduce migraine pain.
Meds for DI
Desmopressin--Vasopressin hypotonic IV fluid
A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect?
Difficulty with speech Rationale: The left hemisphere of the brain is usually the dominant side and is responsible for language. This is always true for right-handed clients and for the majority of left-handed clients. Since this client is recovering from a left-hemisphere stroke, the nurse should anticipate that the client will have aphasia and require speech therapy to establish communication.
What will labs look like for SAIDH?
Dilutional hyponatremia <135, Urine specific gravity >1.030, serum osmolality less than 280 (normal is 285-295)
Signs and symptoms of Dilantin toxicity
Diplopia, nystagmus, confusion, neurologic changes, ataxia (impaired coordination), dizziness, slurred speech.
signs and symptoms of phenytoin toxicity
Diplopia, nystagmus, confusion, neurologic changes, ataxia (impaired coordination), dizziness, slurred speech.
A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect?
Elevated protein Rationale: An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include an increase of protein in the cerebrospinal fluid.
A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?
Encourage the client to take small bites
s/s of DI
Fluid intake 5-20L/day, polyuria 2-20L/day, weight loss, fatigue, tachycardia, hypotension, dilute urine, hypovolemic shock, dehydration--skin turgor, mucus membranes. hypernatremia.
What kind of stroke will a patient have loss of LOC and seizures?
Hemorrhagic stroke
What medications would be given for SIADH?
Hypertonic fluid Salt and diuretics (lasix, but only if serum Na is >125) Declomycin—this drug blocks the effects of ADH in the renal tubules resulting in more dilute urine
Treatment for SIADH
Hypertonic fluid (3% NaCl) demeclocycline (ADH antagonist) may give salt tabs and lasix
left sided stroke
LANGUAGE
A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?
Perform a Romberg's test The nurse should perform a Romberg's test to check the client's ability to maintain an upright position without swaying when standing with feet close together, with eyes open and with eyes closed. The nurse must stand close enough to prevent the client from falling.
A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure?
Protect the client's head. Rationale: The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The client is at greatest risk for injury from hitting his head; therefore the first action is to protect the client's head from injury.
medication for encephalitis
acyclovir, prophylactic seizure meds
headache that is worse at night
brain tumor
lower extremities are stiffly extended, plantar flexion, hyperextended back--no internal rotation
decerebrate
A thrombotic stroke
develops gradually, over minutes to hours, and is the result of a clot (thrombus) which interrupts cerebral blood flow. Thrombotic strokes are commonly associated with atherosclerosis and manifests as numbness or loss of function of the face, arm, or leg usually on one side. The client does not lose consciousness or have seizures.
dysphagia
difficulty swallowing
aphasia, dysphasia
impaired ability to communicate and or comprehend
Speech and movement are more cautious
left sided stroke
A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?
poor impulse control A client who had a stroke involving the right cerebral hemisphere is likely to have personality changes, which can include impulsiveness, confabulation, and poor judgment.
Big safety factor
right sided stroke
impaired judgment
right sided stroke
Right Side of brain is responsible for...
-Attention span -Showing emotions -Ability to solve everyday problems by making deci- sions/plans -Reasoning (understanding jokes...reading in between the lines) -Making judgement calls -Memory recall -Music/art awareness -Controls the left side of the body
Leit Side
-Speaking -Writing -Reading -Math skills -Analyzing info -Planning
Transient ischemic attack (TIA)
A client who has a TIA develops a sudden loss of motor, sensory, or visual function usually lasting less than an hour. It is caused by temporary impairment of blood flow to the brain and is often a warning sign of an impending stroke.
An emergency room nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority? ) A Monitor urinary output B. Administer an osmotic diuretic C. Provide supplemental oxygen D. Initiate seizure precautions
C
A nurse is caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions?
Semi-Fowler's Rationale: To prevent an increase in intracranial pressure, the nurse should position the client with his head midline and the head of the bed elevated 30 degrees. This positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure.
A nurse is caring for a client who has receptive aphasia. Which of the following communication problems should the nurse expect when assessing
The client is unable to understand words or sentences she hears.
A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample?
The client rigidly extends his arms. Rationale: A client who exhibits a decerebrate posture rigidly extends and pronates his four extremities and externally rotates his wrists. Decerebrate posturing indicates severe brain stem injury and late neurologic decline.
A nurse is assessing a client who has a closed head injury and has received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?
The client's serum osmolarity is 310 mOsm/L. Rationale: Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP.
unilateral neglect
The inability to interpret stimuli and events on the contralateral side of a hemispheric lesion. Left-sided neglect is most common with a lesion to the right inferior parietal or superior temporal lobes.--will forget that side exists, not even brush their hair on one side.
expressive aphasia
The inability to produce language ( despite being able to understand language)--broca's area, can use a writing board.
receptive aphasia
The inability to understand language (despite being able to hear it and produce it) --Warnike's area, word salad.
A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?
assess cranial nerves The greatest risk to the client is from increased intracranial pressure (ICP) which may lead to herniation of the brain and death. The nurse should perform neurological assessments including evaluation of the cranial nerves at least every 4 hr. Early neurological changes to be monitoring for include a decrease in the level of consciousness, the development of Cushing's triad (severe hypertension, widened pulse pressure, and bradycardia), and changes in pupillary reaction.
upper extremities are stiffly extended, adducted, internal rotation, palms pronated.
decerebrate
flexion of arms, wrists, adduction of arms.
decorticate
lower extremities are extended, internally rotated, with planter flexion
decorticate
nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect?
hemorrhagic stroke A client who has a hemorrhagic stroke often experiences a sudden onset of symptoms including sudden onset of a severe headache, a decrease in the level of consciousness, and seizures. Hemorrhagic strokes occur when bleeding occurs in the brain caused by the rupture of an aneurysm or arteriovenous malformation, hypertension and atherosclerosis, or trauma.
Apraxia
inability to perform particular purposive actions, i.e. brush your teeth. Think--I can't draw an X
Agnosia
inability to recognize familiar objects, tastes, sounds, and other sensations. Think--I don't "no" what that is, and its agonal
embolic stroke
is caused by an emboli from another area of the body which travels to the brain and causes brain ischemia. They are commonly seen in clients who have atrial fibrillation, heart valve disease, or a recent myocardial infarction. Embolic strokes are characterized by sudden onset of neurological deficits which improve over time. The client does not have a loss of consciousness or seizures.
anxiety, depression
left sided stroke
awareness of deficits
left sided stroke
impaired comprehension related to language, math
left sided stroke
impaired right/left discrimination
left sided stroke
impaired speech/language aphasias
left sided stroke
slow performance, cautious
left sided stroke
symptoms show up on right side of body
left sided stroke
Brian access interventions
long term antibiotics, place pic line
homonymous hemianopsia
loss of half of the field of view on the same side in both eyes
hemiplegia
paralysis of one side of the body
impaired time concept
right sided stroke
impulsive
right sided stroke
rapid performance, short attention span
right sided stroke
symptoms show on left side of body
right sided stroke
tends to minimize problems
right sided stroke
spacial perceptual problems
right sided stroke--fall risk!
decreased urine output, thick sticky urine, fluids volume overload, severely elevated BP, Seizures from low Na+
signs and symptoms of SIADH
hemiparesis
slight paralysis or weakness affecting one side of the body
dysarthria
slurred speech--I can't articulate
labs for DI
urine specific gravity <1.005 urine osmolality <100 (normal is 500-800) hyperosmolar blood, hypernatremia >145
