Exam 4 Neuro and GI

Dx testing for traumatic brain injuries:

-CT -MRI -*glasgow coma scale (GCS), any decline in GCS score needs to be reported to the HCP* -along with GCS we need to fo a focused neuro assessment; pupils are a very important aspect

Splenomegaly:

-Occurs d/t the backflow of blood from the portal vein into the spleen -an enlarged spleen destroys platelets and if it ruptures can cause massive internal bleeding S/S: -thrombocytopenia Safety: avoid -contact sports -roller coasters -wear seatbelts

Hepatorenal syndrome:

-This is often the cause for death for patients with cirrhosis -occurs d/t vasconstriction of the renal arteries -monitoring I & O is key with cirrhosis to monitor for progression to hepatorenal syndrome S/S: -sudden decrease in urine output -elevated BUN & Cr

Hepatic encephalopathy:

-a cognitive syndrome (meaning a sequence of events) -patients will have an elevated serum ammonia because their liver cant clear the ammonia -to decreased ammonia levels we give lactulose -initiate fall precautions for this client because they will be confused -as this progresses it can progress to coma --> we need to preform a GCS on these clients

S/S of ulcerative colitis:

-abdominal pain ---> *LLQ* -*frequent bloody mucous stools that increase with exacerbations* -flatulence -bloating -diarrhea -fever -wt loss -anemia -*tenesmus --> urgent sensation to move bowels*

Risk factors for chron's:

-ages 15-40 -genetics -autoimmune -environmental

Peritonitis chemical risk factors:

-bile -pancreatic enzymes -gastric acid

S/S early stage cirrhosis:

-fatigue -wt changes -anorexia -vomiting -abdominal pain

Risk factors for gullian barre syndrome (GBS):

-infection -illness -vaccination

Surgical treatment for cirrhosis:

-liver transplant -paracentesis --> for comfort

Risk factors for chronic pancreatitis:

-most commonly alcohol use -cystic fibrosis -genetics

Acute pancreatitis:

Acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems -a sudden swelling and inflammation of the pancreas -there will be an increased pancreatic enzyme release results in: -*inflammation* -lipolysis -prolysis -*necrosis and hemorrhage* of pancreatic blood vessels

Dx testing for ALS:

Everything will be negative -MRI -electromyography

Nursing considerations for TPN/PPN:

High risk --> may require a 2 nurse check off Increased risk for hyperglycemia because carbohydrates are administered as a 10% dextrose solution -FBS q 6 hr -administer insulin as needed -monitor for signs of hypo/hyperglycemia -hyper --> polyphagia, polydipsia, polyuria, diaphoretic -hypo --> cool & clammy Daily wts Assess IV site frequently Use a dedicated IV line

Non-surgical treatment for acute pancreatitis:

Mild acute pancreatitis usually resolves itself -patient needs to be *NPO* -hydration is very important -usually antibiotics are not required -*opioids for pain --> do not give morphine because it causes sphincter spasms which exacerbates the pain*

Intracranial pressure (ICP):

Normal 10-14 mmHg -a natural periodic increase in ICP during sneezing, coughing, or straining to have a BM is okay -ICP becomes concerning if it sustains >20 mmHg = neuron death because there is nowhere for the pressure to go

Dx testing for myasthenia gravis :

Tensilon test: -endrophonium is administered -a rapid acting anticholinestrase drug -makes it so that the parasympathetic nervous system works -if strength is improved then myasthenia gravis is diagnosed -myasthenia crisis --> improved strength w/ endrophonium -cholinergic crisis --> decreased strength with endrophonium

treatment for traumatic brain injuries:

Treatment is aimed toward preventing increased ICP Seizure prophylaxis: -theres an increased risk for these patients to have seizures w/severe traumatic brain injuries -maintain seizure precautions -keppra is the med for prophylaxis of seizures Decreased ICP: -mannitol (this med is effective if theres an increase in urine output and a decrease in ICP) -3% sodium chloride (hypertonic solutions will pull water out of the cells to decrease ICP; NO hypotonic solutions like 1/2 NS and D5W) Craniotomy Repeat imaging

the client is scheduled to receive TPN. to administer TPN, which piece of equipment is important for the nurse to obtain? a. infusion pump b. tall intravenous IV pole c. clamp that will be tapes at the bedside d. infusion set that delivers 60 drops/ mL

a. infusion pump

The critical care nurse is assessing a patient whose baseline GCS score in the ED was 5. The current GCS score is 3. What is the nurse's best interpretation of this finding? a. the patients condition is improving b. the patients condition is deteriorating c. the patient will need intubation and mechanical ventilation d. the patients medication regime will need adjustments

b. the patients condition is deteriorating

Which assessment finding reflects increased intracranial pressure (ICP)? a. tachycardia b. unequal pupil size c. decreasing body temperature d. decreasing systolic BP

b. unequal pupil size

which position would the nurse place a client in during the immediate period after injury to the frontal lobe of the brain? a. supine b. side-lying c. low-fowler d. trendelenburg

c. low-fowler

the nurse is caring for a client with chronic inflammation of the bowel. for which most serious complication would the nurse monitor in this client? a. illeus b. pain c. perforation d. obstruction

c. perforation

a client with cirrhosis is scheduled for a liver biopsy. the client asks if there are any postprocedural risks. how would the nurse respond? a. the major risk is pneumonia b. the major risk is site infection c. the major risk is bleeding d. the major risk is liver failure

c. the major risk is bleeding

The nurse is caring for a client admitted with peritonitis. which finding in the medical record is most likely the cause? a. gastritis b. hiatal hernia c. diverticulosis d. bowel obstruction

d. bowel obstruction

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord injuries? a. special pressure-relief devices b. frequent ambulation c. encouraging nutrition d. regular turning and repositioning

d. regular turning and repositioning

Potential complications for gillian barre syndrome (GBS):

respiratory failure -if ventilated --> pneumonia, respiratory acidosis, respiratory alkalosis -autonomic dysreflexia -skin breakdown -loss of autonomy

Surgical treatment for acute pancreatitis:

typically isnt necessary unless it is biliary then a cholexystectomy will be preformed to remove the gallbladder

which information would the nurse include when counseling a client with amyotrophic lateral sclerosis (ALS)? select all a. space planned activities throughout the day b. engage in social interactions with large groups c. request an opioid if leg pain becomes excessive d. anticipate the use of alternative ways to communicate e. use leg restraints to decrease the risk for physical injury

a. space planned activities throughout the day d. anticipate the use of alternative ways to communicate

The patient has portal HTN and hepatic encephalopathy secondary to liver dz and is being treated w/ lactulose. which lab result will the nurse check first to see if the medication is having the desired effect? a. WBC count b. Ammonia level c. Potassium level d. Platelet count

b. Ammonia level

a nurse is reviewing the serum lab data of the client who has an acute exacerbation of Chron's disease. Which of the following lab tests should the nurse expect to be elevated? select all a. Hematocrit b. ESR c. WBC d. Folic acid e. Albumin

b. ESR c. WBC

a client with colitis inquires whether surgery eventually will be necessary. when teaching about the disease and its treatment, which would the nurse emphasize? a. medical treatment is curative; surgery is not required b. for most clients surgery is recommended only if nonsurgical treatments have been unsuccessful c. for most clients surgery is recommended early in the course of treatment d. medical treatment is all that will be needed if the client can maintain emotionally stable

b. for most clients surgery is recommended only if nonsurgical treatments have been unsuccessful

A nurse is caring for a client who has increased ICP and new prescription for mannitol. For which of the following adverse effects should the nurse monitor? a. hyperglycemia b. hyponatremia c. hypervolemia d. oliguria

b. hyponatremia

A nurse is assessing a client who reports a severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudsinki's signs. Which of the following actions should the nurse preform first? a. administer antibiotics b. implement droplet precautions c. initiate IV access d. decrease bright lights

b. implement droplet precautions

the nurse is caring for a client with hepatic encephalopathy and ascites. which elements are important to include in the clients diet? select all a. high fat b. low sodium c. high vitamins d. moderate protein e. low carbohydrates

b. low sodium c. high vitamins d. moderate protein

which nursing intervention is anticipated for a client with gullian barre syndrome? a. providing a straw to stimulate the facial muscles b. maintaining ventilator settings to support respiration c. encouraging aerobic exercises to avoid muscle atrophy d. administering antibiotic medication to prevent pneumonia

b. maintaining ventilator settings to support respiration

a client is admitted with a suspected cervical spinal cord injury. what is the nurses priority action for this client? a. assess cardiac sounds b. manage the clients airway c. check oxygen saturation level d. perform a neurological assessment

b. manage the clients airway

the nurse is caring for a client that is scheduled to have a percutaneous liver biopsy. which assessment findings warrant the postponement of the procedure? select all a. hemosiderosis b. marked ascites c. hepatic cirrhosis d. hemoglobin < 9 e. platelet count of 150,000

b. marked ascites d. hemoglobin < 9

Which finding would the nurse expect when assessing a client who is in an early stage of multiple sclerosis? select all a. headache b. nystagmus c. skin infection d. scanning speech e. intention tremors

b. nystagmus d. scanning speech e. intention tremors

After many years of coping with ulcerative colitis, a client makes the decision to have a colectomy as advised by the primary HCP. which is most likely the significant factor that affected the clients decision? a. it is temporary until the colon heals b. surgical treatment cures ulcerative colitis c. ulcerative colitis can progress to chron disease d. without surgery, eating table foods is contraindicated

b. surgical treatment cures ulcerative colitis

Labs for traumatic brain injuries:

because of the direct impact of antidiuretic hormone (which causes the body to hold onto fluid) there will be increased fluid in the brain we need to monitor: -serum sodium -serum osmolality

The patient with end-stage liver dx is talking to the nurse about being on the transplant list. which statement by the patient is cause for greatest concern? a. I have a family hx of diabetes b. I had symptoms of asthma when I was a kid c. I guess i should cut back on my alcohol consumption d. I am not very good about taking prescribed medication

c. I guess i should cut back on my alcohol consumption

The nurse is assessing a client with chron disease who is scheduled for an upper gastrointestinal series. which condition necessitate the cancellation of the procedure? a. hemorrhoids b. hyperkalemia c. inflamed colon d. colon perforation

d. colon perforation

which statement by the client indicated a need for further teaching by the nurse about preventing back injuries? a. i need to loose weight because im too big b. i should not sit or stand for a long period of time c. it would be best if i could get ergonomic office furniture d. exercise is not going to help my back very much

d. exercise is not going to help my back very much

the nurse is evaluating a client who has been receiving medical intervention for a diagnosis of chron disease. which expected outcome is most important for this client? a. preforms skin care b. tolerates oral fluids c. experiences less abdominal cramping d. gains a half pound (0.2 kg) per week

d. gains a half pound (0.2 kg) per week

A patient with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the ED. what is the priority nursing assessment? a. determine the level at which the patient has intact sensation b. assess the level at which the patient has retained mobility c. check the BP and pulse for signs of spinal shock d. monitor respiratory effort and oxygen saturation level

d. monitor respiratory effort and oxygen saturation level

For which reason would a lumbar puncture be preformed on a client? select all a. confirming spinal cord injuries b. assessing sensory nerve problem c. measuring blood flow in many areas d. reading cerbrospinal fluid pressure e. injecting contrast medium for diagnostic study

d. reading cerbrospinal fluid pressure e. injecting contrast medium for diagnostic study

which short term goal would a nurse develop when planning care for a client 1 wk after the client experienced a spinal cord injury at the T3 level? a. the client will understand limitations b. the client will consider lifestyle changed c. the client will preform independent ambulation d. the client will carry out personal hygiene activities

d. the client will carry out personal hygiene activities

Labs for spinal cord injuries:

labs depend on the patients condition, there are no labs that specifically says that the patient has a spinal cord injury H&H --> if from a hemorrhage ABG's if respiratory distress -if the spinal cord injury is at C2, C3 or below the respiratory system will not be able to expand and the patient will need to be intubated -injury above C2 or C3 damage is permanent

Labs for gullian barre syndrome (GBS):

no labs are specifically associated with gullian barre syndrome -ESR/ CRP --> if inflammation is present -Cr/BUN --> if they are getting fluids we need to check their kidney function

Incomplete spinal cord injury:

results in some function and/ or feeling below the injury -if a partial spinal cord injury isn't completely immobilized it can turn into a complete spinal cord injury -we nee to immobilize the area to prevent progression to a more serious spinal cord injury

Treatment for ALS:

there is no cure -treatment is management of symptoms --> to help them stay as strong and independent as possible

Labs for acute pancreatitis:

*Increased amylase and lipase* -amylase levels will increase within 12-24 hrs and remain elevated for 2-3 days -lipase levels will elevate after amylase and remain elevated for 2-3 wks -increased trypsin -increased elastase -*increased glucose* --> because the pancreas produces insulin -decreased calcium -decreased Mg -ESR and CRP -if hepatobiliary is involved --> elevated bilirubin, AST, & ALT

Risk factors for traumatic brain injuries:

-Age --> young males -gender --> males (they tend to play more sports) -substance use -contact sports (concussions are included)

Dx testing for intracranial pressure (ICP):

-CT scans -MRI

Non-surgical treatment for cirrhosis:

-ETOH absence --> for all clients even if it not ETOH induced cirrhosis -treat complications -*avoid acetaminophen, alcohol and smoking, and illicit drugs*

Gullian Barre syndrome (GBS):

-Rare acute inflammatory condition that is affecting the *peripheral nervous system* resulting in *gradual* muscle weakness or paralysis -*starts distal in the toes and gradually works its way up the body* -NOT the brain and spinal cord -clients are alert and aware of whats going on -this syndrome is triggered by an illness/ infection causing demylenation -takes 1-2 weeks until re-myelination begins -clients that experience complete paralysis from the neck down requires ventilation to breath

dx testing for acute pancreatitis:

-ultrasound -CT scan

Labs for chron's:

CBC: -low H&H --> d/t the malabsorption leading to anemia -hypoalbuminemia -look at MCV CMP: -hyponatremia -hypokalemia -elevated WBC's CRP/ESR --> elevated Stool sample for: -C & S -Ova -Parasites

Multiple sclerosis:

Chronic disease --> a demyelination with plaque in white matter (white matter is in the brain) -affects the *central nervous system* -period of remission and exacerbation -usually dx is at 20-30 yrs old -most cases are relapsing-remitting

Mannitol:

Class --> osmotic Diuretic MOA: -increases serum osmolarity to decrease cerebral fluid by excretion -the higher the dose the more fluid will be secreted Safety: -administer through large bore IV or central line W/ inline filter -hold is serum osmolality is above 320 -contraindicated in patients with pulmonary edema, active intracranial bleeding, significant hypovolemia, and use cautiously with HF patients

TPN:

Total parenteral nutrition -*must be given through a central line* (PICC lines, subclavian CVC, femoral CVC, internal jugular lines) -*not compatible with anything!* -a concentrated form of nutrition --> more calories in a small volume -lipids are administered with TPN separately

The nurse is caring for a patient with cirrhosis and portal HTN. Which statement by the patient is cause for greatest concern? a. I'm very constipated and have been straining during bowel movements b. I can't button my pants anymore because my belly is so swollen c. I have a tight sensation in my lower legs when I forget to put my feet up d. When i sleep, i have to sit in a recliner so that I can breath more easily

a. I'm very constipated and have been straining during bowel movements

A patient underwent an exploratory laparotomy 2 days ago. the HCP should be called immediately for which assessment finding? a. abdominal distention and rigidity b. absent or hypoactive bowel sounds c.nausea and occasional vomiting d. displacement of the NG tube

a. abdominal distention and rigidity

Peritonitis develops in a client who had surgery for a ruptured appendix. which clinical findings related to peritonitis should the nurse expect the client to exhibit? select all a. fever b. hyperactivity c. extreme hunger d. urinary retention e. abdominal muscle rigidity

a. fever e. abdominal muscle rigidity

a client with a long hx of alcohol abuse is admitted to the hospital with ascites and jaundice. a diagnosis of hepatic cirrhosis is made. which is a nursing priority? a. institute fall prevention and safety measures b. evaluate coping skills c. measure abdominal girth daily d. test stool specimens for blood

a. institute fall prevention and safety measures

a nursing is caring for a client who has a halo fixator device with vest for a complete cervical spinal cord injury. which assessment finding will the nurse report to the primary HCP? a. purulent draining from the pin sites on the clients forehead b. painful pressure injury under the collar c. inability to move legs or feet d. oxygen saturation of 95% on room air

a. purulent draining from the pin sites on the clients forehead

Cirrhosis:

*Irreversible* liver tissue scarring and fibrosis -caused by --> chronic inflammation in stages (a chronic slow progressing disease that develops overtime) -extensive degeneration and destruction of liver cells -we need to identify if they have a fatty liver so that we can minimize the progression to worse stages -fibrotic tissue creates hard and firm nodules

Peritonitis:

*Life threatening* acute inflammation and infection of the visceral/ parietal peritoneum and endothelial lining - will spread and increase in intensity very rapidly (they will die if its not treated) -normally theres 50 mL of transudate -bacterial contamination of the transudate (fluid) created an inflammatory response -causes vasodilation and increased capillary permeability

Myasthenia gravis:

*autoimmune* -attacks muscle receptors that control *voluntary muscles* -antibodies block acetylcholine receptors --> meaning the parasympathetic nervous system isnt working properly causing voluntary movements to not occur the same way we want them to -thymus (glad located mid sternum that immune regulates) contributes with overproduction of antibodies and is often enlarged (thymus is overactive)

Ascites:

*biggest risk for respiratory compromise* -fluid accumulation is happening because of the portal HTN -patients are at risk for hypovolmic shock d/t 3rd spacing -at risk for respiratory failure from abdominal pressure -treatment for ascites --> paracentesis -low albumin levels with cirrhosis contributes to increased edema

S/S acute pancreatitis

-*PAIN* --> mid epigastric pain and LUQ pain that worsens in the supine position -N/V -wt loss -jaundice -turner's and cullen's sign --> will present as ecchymosis d/t hemorrhaging of the pancreas

S/S or peritonitis:

-*Right abdomen* -*Rebound tenderness* -*Fever* -abdominal pain -distended abdomen -N/V, anorexia -diminished bowel sounds -inability to pass gas -constipation or diarrhea -tachycardia -dehydration -decreased urine output -hiccups -respiratory compromise

Labs for chronic pancreatitis:

-*amylase* may be normal or slightly elevated -*lipase* may be normal or slightly elevated -*glucose* will be elevated -ESR and CRP will be elevated -if hepatobiliary is involved there will be elevated bilirubin, AST, and ALT

S/S increased intracranial pressure (ICP)

-*decreased LOC --> early sign* -restlessness, irritable, and confused -headache -N/V (concerned for increased ICP even more when the patient is vomiting) -aphasia -dysarthria -sensorimotor changes --> noncreative pupils, cranial nerve dysfunction -ataxia -seizures (at highest risk the 1st 24 hrs after injury)

S/S myasthenia gravis:

-*weakness* -weakness progresses throughout the day as they get tired -the best time of day for these patients is the morning Face: -ptosis --> eye dropping -mask like appearance --> very sleepy -strabismus/ diplopia --> extraocular muscle movement Throat/ neck: -frequent choking/ gagging when eating -slurred speech/ hoarse voice Arms/ legs no energy severe cases --> respiratory system SOB

Risk factors for cirrhosis:

-Hep C (in the US its the leading cause \) -ETOH abuse -bile duct disease -non-ETOH fatty liver disease --> results from obesity, DM, metabolic syndrome -drugs and toxins -genetics

Surgical treatment for Chron's:

-I & D of fistulas -resection -ileostomy for obstruction or megacolon -colostomy --> the stoma should be red/pink, moist, and protrude 1-3 cm from the abd wall

S/S late stage cirrhosis:

-Jaundice --> s/t excess bilirubin -icterus -pruritus -rashes, palmar erythema -petechiae, purpura, ecchymosis --> d/t increased PT and INR -spider angiomas -perfuse ascites -edema -vitamin deficiencies -terry's nails --> nail bed is white with pallor and one area of redness

S/S of chronic pancreatitis:

-PAIN! (will be continuous, burning like, and gnawing) -abd tenderness -ascites -dyspnea -orthopnea -steatorrhea -wt loss -jaundice -dark urine -hyperglycemia --> polyuria, polyphagia, polydipsia

Nursing interventions for peritonitis:

-VS --> they will have a fever, tachycardia, increased BP, and respiratory compromise -I&O --> they will have decreased urine output -electrolyte replacement -fluid resuscitation -pain management -prepare for surgery

Dx testing for chron's:

-X-ray -CT -magnetic resonance enterography (MRE) -colonoscopy --> gold standard -endoscopy

Dx testing for cirrhosis:

-X-ray --> to assess for hepatomegaly -CT scan -ultrasound elastography (fibroscan) -liver biopsy

S/S of chron's:

-abdominal pain --> *RLQ* -*frequent loose stools* -*rigid abdomen if fistula/ peritonitis is developing* -flatulence -bloating -diarrhea -fever -wt loss -anemia -*tenesmus --> urgent sensation to move bowels

Mild s/s of traumatic brain injuries:

-appear dazed or stunned -photophobia --> sensitivity to light -phonophobia --> sensitivity to sound -N/V -balance/ gait problems -feeling mentally foggy -difficulty concentrating/ remembering -drowsiness -sleep changes -emotional lability

potential complications for ALS:

-aspiration pneumonia -respiratory failure -skin breakdown and pressure injuries -loss of autonomy

Nursing interventions for cirrhosis:

-manage complications -emotional support -measure abdominal girth (to identify how much fluid is in the abdominal cavity) -daily wts -VS -monitor I & O -bleeding precautions --> soft bristle toothbrush, electric razor, fall precautions

Nursing interventions for Chron's:

-monitor perineal skin -daily wts -manage drainage pouches if they have a colostomy -pre and post op care for colostomy -pt eduction on how to assess and manage exacerbations and remissions

Risk factors for acute pancreatitis:

-most common --> gallstones -steroid use -infection (mumps) -autoimmune disorders -hypercalcemia and hypertriglyceridemia -scorpion stings

Potential complications for chronic pancreatitis:

-pancreatic infection -hemorrhage -acute kidney failure -paralytic ileus -atelectasis --> pneumonia -type II DM -necrotizing hemorrhagic pancreatitis (NHP) -ARDS -MODS

Esophageal varices and gastric varices:

-patients are at risk for rupture/ bleeding -*protect the airway* -at risk for hypovolemic shock d/t blood loss S/S: -hematemesis -melena -spontaneous Avoid: -lifting heavy objects (it increases intra abdominal pressure) -eating hard foods

Hepatopulmonary syndrome:

-results from excessive ascites that increase intrathroacic pressure and limit thoracic expansion S/S: -dyspnea

Nursing interventions for ALS:

-safety -focused respiratory assessment -focused neuromuscular assessment --> because they loose strength in gross motor movement which progresses to fine motor -support nutrition, breathing, and feeding -reposition and skin care -promote autonomy

potential complications of peritonitis:

-sepsis --> results in the infection becoming systemic -hypovolemic shock --> from 3rd spacing and ascites -renal failure --> fluid shifts can result in an AKI -respiratory failure --> from abdominal pressure on the diaphragm -death

Causes of increased intracranial pressure (ICP):

-stroke -traumatic brain injury -infection --> meningitis, encephalitis -brain/ cranial surgery -brain tumors -hydrocephalus

S/S of gullian barre syndrome:

-we don't expect changes in consciousness/ awareness -paresthesia that progresses to paralysis -as weakness/ paralysis progress --> *DTR decreases (areflexia)* -may progress to cranial nerves -may progress to respiratory failure and autonomic dysfunction -may have trouble swallowing and their speech may be impacted -mild muscle atrophy (the more severe GBS the longer it takes to recover; months -years)

Ulcerative colitis:

Chronic inflammation of *rectum and sigmoid colon* (always start here), ascending through the large intestine -mucosa hyperemic (increased blood flow), edema, and eryhthema -patients will have ulcerations, abscesses, and bleeding -10-20 liquid *BLOODY* stools per day --> with an acute flare up

Chrons:

Chronic inflammation of the small intestine, colon, or mouth -*can occur from the mouth to the anus* -inflammation causes thickened bowel wall cobblestones -malabsorption d/t chrons can lead to anemia -patients will have 5-6 soft, loose stools per day (NO blood)

a client has been diagnosed with primary progressive multiple sclerosis (PPMS) and the nurse is providing education at the clinic. what statement by the client indicates the need for further teaching? a. It's important I workout in the afternoon so my muscles are warmed up b. I can alternate wearing my eye patch between eyes for double vision c. I should keep my home clutter free so I don't fall d. I always keep my medications in the same place

a. It's important I workout in the afternoon so my muscles are warmed up

a client who is obese and has a hx of alcohol abuse is admitted to the hospital with a diagnosis of acute pancreatitis. which is an appropriate initial client treatment goal? a. decreased pain b. selection of appropriate food choices c. joining alcoholics anonymous d. a loss of 4 Ibs (1.8 kg) per week

a. decreased pain

a client with a T6 spinal cord injury who is on the rehab unit suddenly develops facial flushing and reports a severe headache. BP is elevated and the heart rate is slow. which action does the nurse take first? a. help the client sit up b. check for fecal impaction c.loosen the clients clothing d. insert a straight cath

a. help the client sit up

Which information would the nurse expect to be reported in the health hx of a client with a suspected dx of myasthenia gravis who sees the primary HCP because of fatigue, double vision, and muscle weakness? a. muscle weakness improving after a period of rest b. symptoms worse in the morning upon awakening c. intermittent periods of hyperactivity d. slow, insidious onset of muscle weakness

a. muscle weakness improving after a period of rest

a client with colitis has had a hemicolectomy. three days after the surgery the nurse identifies that the client has abdominal distention, absent bowel sounds, and vomitus of 300 mL of dark green viscous fluid. the nurse contacts the primary HCP and anticipates which prescription? a. nasogastric tube for decompression b. antiemetic for N/V c. IV lactated ringer for fluid replacement d. stat electrolytes to assess for probable electrolyte imbalance

a. nasogastric tube for decompression

the nurse is admitting a client with probable diagnosis of meningitis. what signs and symptoms might the nurse expect when assessing this client? select all a. photophobia b. nystagmus c. decreased level of consciousness d. decreased movement such as hemiparesis e. disorientation to person, place, and time

a. photophobia b. nystagmus c. decreased level of consciousness d. decreased movement such as hemiparesis e. disorientation to person, place, and time

which type of rehab is an essential component to a clients recovery from Gullain-Barre syndrome? a. physical therapy b. speech exercises c. fitting with a vertebral brace d. follow-up on cataract progression

a. physical therapy

a client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. which nursing intervention is the priority for the client at this time? a. positioning the client to maximize ventilation potential b. taking vital sings every 2 hrs c.inserting an indwelling urinary catheter d. monitoring the clients nutritional status

a. positioning the client to maximize ventilation potential

A nurse in the ED is completing an assessment of a client who has suspected stomach perforation d/t a peptic ulcer. Which of the following findings should the nurse expect? select all a. rigid abdomen b. tachycardia c. elevated BP d. circumoral cyanosis e. rebound tenderness

a. rigid abdomen b. tachycardia e. rebound tenderness

Which action would the nurse take when a client admitted to the hospital after a car accident has clear drainage oozing from the ear? a. test the fluid for glucose and apply a sterile dressing b. position the client so that the unaffected ear is dependent c. cover the area with sterile gauze while applying slight pressure d. clean the clients outer ear with NS and insert a cotton ball

a. test the fluid for glucose and apply a sterile dressing

A nurse is caring for a client who is post-procedure following a lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? select all a. Use GCS when assessing the client b. Assist the client to a supine position c. Administer an opioid medication d. Encourage the client to increase fluid intake e. instruct the client to preform deep breathing and coughing exercises

b. Assist the client to a supine position c. Administer an opioid medication d. Encourage the client to increase fluid intake

The nurse reviews the lab results of a client with acute pancreatitis. which test is significant in determining the clients response to treatment? a. platelet count b. amylase level c. RBC count d. erythrocyte sedimentation rate

b. amylase level

the nurse is providing discharge instruction to a client diagnosed with cirrhosis and varices. which information would the nurse include in the teaching session? select all a. adhering to a low-carb diet b. avoiding aspirin and aspirin containing products c. limiting alcohol consumption to tow drinks weekly d. avoiding acetaminophen and products containing acetaminophen e. avoiding coughing, sneezing, and straining to have a bowel movement

b. avoiding aspirin and aspirin containing products d. avoiding acetaminophen and products containing acetaminophen e. avoiding coughing, sneezing, and straining to have a bowel movement

the nurse is caring for a client following a cerebral angiography. which assessment finding will the nurse report immediately to the primary HCP? a. discomfort at the injection site b. bleeding from the injection site c. fatigue and weakness d. mild headache

b. bleeding from the injection site

A nurse is completing discharge teaching with a client who has Chron's disease. Which of the following instructions should the nurse include in the teaching? a. decrease intake of calorie-dense foods b. drink canned protein supplements c. increase intake of high fiber foods d. take a bulk-forming laxative daily

b. drink canned protein supplements

which action would the nurse take first when the family member of a client with Guillian-barre syndrome walks to the nurses station and informs the nurse that the client is having difficulty breathing? a. notify the clients health care provider by telephone b. go with the family member to assess the client c. send the nursing assistive personnel to take VS d. assure the family member that this is expected for the disease

b. go with the family member to assess the client

The nurse has just admitted a patient with bacterial meningitis who reports a severe headache with photophobia (sensitivity to light) and has a temp of 102.6 orally. Which prescribed intervention should be implemented first? a. administer codeine 15 mg orally for the patient's headache b. infuse ceftriaxone 2000 mg IV to treat the infection c. give acetaminophen 650 mg orally to reduce the fever d. give furosemide 40 mg IV to decrease intracranial pressure

b. infuse ceftriaxone 2000 mg IV to treat the infection

the nurse is assessing a client with a suspected diagnosis of multiple sclerosis. which assessment findings will the nurse expect? select all a. resting tremors b. memory loss c. muscle spasticity d. fatigue e. diplopia f. dystarhria

b. memory loss c. muscle spasticity d. fatigue e. diplopia f. dystarhria

The RN notes that a patient with myasthenia gravis has an elevated temp 102.2, and increased HR 120 beats/min, and a rise in BP 158/94, and is incontinent of urine and stool. What is the nurses best action at this time? a. administer an acetaminophen suppository b. notify the HCP immediately c. recheck VS in 1 hr d. reschedule the patients physical therapy

b. notify the HCP immediately Rationale: symptoms are characteristics of a myasthenic crisis

a client is admitted to the hospital with laennec cirrhosis and chronic pancreatitis. bile salts (bile acid factor) are prescribed, and the client asks why they are needed. how would the nurse respond? a. they stimulate prothrombin production b. they aid in the absorption of fat-soluble vitamins c. they promote bilirubin secretion in the urine d. they help the common bile duct contract stronger

b. they aid in the absorption of fat-soluble vitamins

Which possible cause would the nurse suspect in a client with a head injury who has fixed, dilated right pupil, responds only to painful stimuli, and exhibits flexion (decorticate) positioning? a. meningeal irritation b. subdural hemorrhage c. cerebral compression d. medullary compression

c. cerebral compression

The nurse is assessing a patient with a neurologic health problem and discovers a change in LOC from alert to lethargic. What is the nurse's best action? a. preform a complete neurologic assessment b. assess the cranial nerve functions c. contact the rapid response d. reassess the patient in 30 min

c. contact the rapid response

the nurse is preparing to conduct a focused neurological assessment for a client who had a traumatic brain injury. which assessment finding is the immediate concern of the nurse? a. disorientation b. numbness of both arms c. decreased level of consciousness d. report of headache

c. decreased level of consciousness

which complication would the nurse anticipate when planning care for a client who is admitted with a crushing injury to the spinal cord at the level of phrenic nerve origin? a. prolonged coma b. ventricular fibrillation c. diaphragmatic paralysis d. vagus nerve dysfunction

c. diaphragmatic paralysis

which action would the nurse include in the plan fo care for a client admitted with peritonitis secondary to a ruptured appendix? a. placing the client in the supine position b. providing a low residue diet c. inserting a nasogastric tube d. scheduling an obstructive series

c. inserting a nasogastric tube

A nurse is assessing a client who has pancreatitis. Which of the following actions should the nurse take to assess the presence of Cullen's sign. a. tap lightly at the costovertebral margin on the client's back b. palpate the RLQ c. inspect the skin around the umbilicus d. auscultate the area below the scapula

c. inspect the skin around the umbilicus

the nurse provides dietary teaching for a client with acute exacerbation of ulcerative colitis, and afterward the client makes a list of foods that can be included in the diet. which food choices indicate that the teaching by the nurse is effective? select all a. orange juice b. creamed soup c. jelly sandwich d. lean roast beef e. scrambled eggs

c. jelly sandwich d. lean roast beef e. scrambled eggs

a client with an obstruction of the pancreatic duct is diagnosed with acute pancreatitis. a subtotal pancreatectomy is performed. the nurse would monitor the client for which postoperative complication? a. constipation b. cholecystitis c. paralytic ileus d. respiratory distress

c. paralytic ileus

The patient with advanced cirrhosis has: massive ascites, peripheral-dependent edema in the lower extremities, nausea and vomiting, and dyspnea related to pressure on the diaphragm. which indicator is the most reliable for tracking fluid retention? a. auscultating the lung fields for crackles every day b. measuring the abdominal girth every morning c. performing the daily weights with the same amount of clothing d. checking the extremities for pitting edema and comparing with baseline

c. performing the daily weights with the same amount of clothing

a client who sustained a recent cervical spinal cord injury reports having a throbbing headache and feeling flushed. the clients BP is 190/110. what is the nurses priority action at this time? a. preform a bladder assessment b. insert an indwelling urinary catheter c. place the patient in a sitting position d. turn on a fan to cool the patient

c. place the patient in a sitting position

The nurse is caring for a client with a bowel obstruction. which assessment findings indicate the possible onset of peritonitis? select all a. diarrhea b. bradycardia c. rebound tenderness d. diminished bowel sounds e. rigid, boardlike abdomen

c. rebound tenderness d. diminished bowel sounds e. rigid, boardlike abdomen

to prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the primary health care team is a nursing priority? a. nutritional therapy b. physical therapy c. respiratory therapy d. occupational therapy

c. respiratory therapy

One month after abdominal surgery, a client is readmitted to the hospital with recurrent abdominal pain and fever. the medical diagnosis is fistula formation with peritonitis/ the nurse would maintain the client in which position? a. supine b. right lateral recumbent c. semi-fowler d. the position that the client prefers

c. semi-fowler

a client was admitted to the hospital unit a few minutes ago with a new diagnosis of right hemiparesis and aphasia, which resulted from a traumatic brain injury. which of the following interventions is a priority for this client at this time? a. contact the physical therapist (PT) to plan care to increase the clients mobility b. contact the occupational therapist (OT) to assess the clients ADL ability c. contact the unit social worker (SW) to talk with the family about the clients discharge

d. contact the speech-language pathologist (SLP) to schedule a swallowing study

Which instruction would the nurse include when planning care with a client newly diagnosed with myasthenia gravis who is experiencing diplopia, ptosis, and mild dysphagia? a. restrict the diet to liquids and foods that are pureed b. perform ROM exercises c. remember to use stool softener daily d. take prescribed anticholinergic medications on schedule

d. take prescribed anticholinergic medications on schedule

Which information would the nurse expect the client who has multiple sclerosis with hand tremors to report? a. the tremors increase when I fall asleep b. the tremors increase when i feel fatigues c. the tremors increase when i become nervous d. the tremors increase when i preform an activity

d. the tremors increase when i preform an activity

S/S MS:

*Charcot's triad* -intention tremors --> when they go to do something the tremor will occur -dysarthria --> difficulty speaking d/t weakness of muscles during times of exacerbation -nystagmus --> shaking of the eyes -fatigue -muscle weakness and spacticity -flexor muscle spasms -dysmetria --> cannot coordinate movements with where they need to go (they will be at risk for falls) -paresthesia -hypoalgesia --> decrease in sensation -ataxia -dysphagia -scotomas -diplopia -decreased visual and hearing acuity -tinnitus -vertigo -bowel and bladder dysfunction -alterations in sexual dysfunction -depression -cognitive changes

Nursing interventions for increased intracranial pressure (ICP):

-*elevate HOB to improve perfusion at least 30 degrees* -*maintain the head midline --> turning their head side to side can cause jugular compression; increasing ICP* -*maintain a quiet environment* -*keep the room lights low* -provide oxygen therapy tp prevent hypoxia for patients with oxygenation saturation less than 94% -avoid clustering care --> it creates too much stimulation for the patient and increases ICP -hyperoxygenate the patient before and after suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation and cerebral arteries -provide airway management -closely monitor for early interventions to prevent secondary brain injury --> BP, HR & rhythm, O2 sat, blood glucose, and body temp

Treatment for spinal cord injuries:

-Immobilization and stabilization -main treatment --> preventing and managing complications (urinary retention, constipation, pneumonia, pressure injuries etc.) -cervical collar --> once its on we dont take it off -halo traction --> used for cervical fractures, high T fractures, patient can be in this for weeks to months

Moderate --> severe s/s of traumatic brain injuries:

-Seizures -Pupillary changes -Clear drainage from nose or eyes → CSF we test glucose (Will leave a ring on a tissue and patient will have constant swallowing) -Pts at most concern for CSF → facial fracture -CSF protects the brain so if its leaking the brain isn't being protected -Paresthesia -Ataxia → whole gait is impacted -Confusion -Difficulty speaking -Sleep changes -Emotion lability -Coma

Potential complications for myasthenia gravis:

-aspiration pneumonia -myasthenic crisis --> more anticholinestrase medication is needed (presents with severe weakness) -cholinergic crisis --> antidote is atropine; also presents with severe weakness the tesilon test is used to determine if its a myasthenic crisis or cholinergic crisis -impaired self image -loss of autonomy

Nursing interventions for MS:

-focused neuromuscular assessment -monitor I & O/ bowel and bladder function -maintain safety -monitor gait -assist with ADLs -assess ability to swallow -advoacte for IDT (interdisciplinary team) referrals -plan activities to promote rest -teach visual scanning --> d/t visual impairment -check water temp of bath before entering --> d/t hypoalgia -avoid rigorous exercise and activity that increases body temp (increase in body temp leads to exacerbations but we still want to encourage them to be as active as possible) -assess and assist with main management

Potential complications of MS:

-pain -falls and injuries -pneumonia --> during times of exacerbation they experience trouble swallowing which can result in aspiration -sexual dysfunction -loss of autonomy -depression -cognitive impairment

Amyotrophic lateral sclerosis (ALS):

-progressive deterioration of motor neurons in the CNS -sclerosis --> thinning of nerves within muscle and will result in the patient not being able to move well -life expectancy 3-5 yrs after diagnosis

S/S of ALS:

-progressive weakness that starts in hands, legs, or feet which results in difficulty walking and moving -difficulty holding head up and maintaining posture --> dyspnea --> respiratory failure -dysarthria -dyspahgia -uncontrollable crying or laughing -incontinence bowel and bladder -constipation

nursing interventions for traumatic brain injuries:

-promote rest and decrease stimuli -HOB elevated >30 degrees -serial neurological assessments q 1-4 hrs depending on the severity of the trauma -GCS -VS --> increase in BP, decreased HR, and irregular respirations indicates cushings triad -monitor labs --> serum sodium and osmolarity -monitor for seizure activity -VTE prophylaxis -patient education -go to ED if s/s increased ICP -goal BP is to stay under 160

Treatment for increased intracranial pressure (ICP):

-sedation -CSF drainage -osmotic therapy --> *mannitol*, hypertonic saline IV fluid -loop diuretics (possible but depends on the cause) -craniectomy --> surgical removal of the brain from the skull -hyperventilation --> will constrict blood vessels to decrease ICP

Dx testing for spinal cord injuries:

-spine CT -MRI (preferred because it gives more detail than a CT) -X-rays (if theres a fracture) -DEXA scan for long term complications of osteoporosis may be needed because these patients will be non weight bearing

Halo traction nursing interventions:

Assess neuro, including motor and sensation q 4 hrs Assess respiratory system and for s/s of dysphagia --> patients are at risk for aspiration and dysphagia because they are in a fixed position Assess skin every shift: -wool from underneath the vest needs to be changes out -the patient will be lying supine and the vest is loosened just enough to take out the old wool and replace with new wool -pin care needs to be done --> 1 swab per pin w/ NS -assess pin sites for s/s cellulitis -we may need to use a flashlight to look for skin breakdown underneath the vest Meticulous skin care: -soap and water every day; skin needs to be dried thoroughly -sponge bathes for these patients only; NO showers Keep wrench with traction at all times Sleeping: -we can put a rolled towel underneath the halo to reduce pressure on the back of their head slightly Unbuckling traction: -patient needs to be lying supine Monitor weights Diet: -high in protein and calcium CPR: -lie the patient flat and take off the anterior portion of the vest but leave the posterior in place Monitor for infection

Potential complications for spinal cord injuries:

Autonomic dysreflexia: -caused by GI, GU, or vascular stimulation -*sudden significant rise in systolic and diastolic BP accompanied by bradycardia* -High risk factors --> bladder distention, UTI, epididymis/ scrotal compression, constipation -place patients in a sitting position or return them to their previous safe position -*assess GI and GU systems: bladder scan 1st, catheter, fecal disimpactation* -pneumonia -respiratory distress/ failure -pressure injuries -venous thromboembolism -hypothermia/ hyperthermia -osteopneia/ osteoporosis --> d/t fractures and lack of weight bearing activities -neurogenic shock -pain -depression -loss of autonomy

Nursing interventions for gillian barre syndrome (GBS):

Focused respiratory assessment -airway management -we need to prepare to intubate --> suction set-up, ambu bag -assess swallowing Focused cardiovascular assessment: -pts are at risk for dysrhythmias (when the lungs are impacted the heart can be too and is a late finding), orthostatic hypotension, HTN (d/t changes in nerves sensing auto regulation) Focused neuro assessment: -at risk for autonomic neuropathy and/ or autonomic dysfunction --> monitor I & O -risk for body temp regulation impairment Reposition frequently/ maintain skin integrity If intubated --> they will have a hard time communicating Assess pain

a client is admitted to the hospital with severe back and abdominal pain, nausea, and occasional vomiting, and and oral temp of 101. the client reports drinking 6-8 beers a day. a diagnosis of acute peritonitis is made. based on the data presented, which clinical finding is a primary nursing concern? a. acute pain b. inadequate nutrition c. electrolyte imbalance d. disturbed self-concept

a. acute pain

Which clinical manifestations would the nurse expect for a client who has myasthenia gravis? a. blurred vision with episodes of vertigo b. tremors of the hands when lifting objects c. partial improvement of muscle strength with mild exercise d. involvement of distal muscles more than proximal muscles

a. blurred vision with episodes of vertigo

which assessment finding is most consistent with myasthenic gravis? a. difficulty breathing b. decline in physical mobility c. disturbed sensory perception d. decreased tolerance to activity

a. difficulty breathing

paracentesis is prescribed for a client recently admitted to a medical unit. the nurse recalls that the procedure is preformed for which reasons? select all a. extract peritoneal fluid b. improve respiratory status c. decrease intrapleural fluid d. increase intra-abdominal tension e. obtain peritoneal fluid for culture

a. extract peritoneal fluid b. improve respiratory status e. obtain peritoneal fluid for culture

which reported clinical manifestations would the nurse expect from a client with ulcerative colitis? select all a. fever b. diarrhea c. gain in weight d. spitting up blood e. abdominal cramps

a. fever b. diarrhea e. abdominal cramps

In which position would the nurse place a client with a spinal cord injury experiencing autonomic dysreflexia? a. high fowler b. left side-lying c. right side-lying d. flat on the back

a. high fowler

A client with a long hx of alcohol abuse develops cirrhosis of the liver. the client exhibits the presence of ascites. which would the nurse conclude is the most likely cause of the clients ascites? a. impaired portal venous return b. impaired thoracic lymph channels c. excess production of serum albumin d. enhanced hepatic deactivation of aldosterone secretion

a. impaired portal venous return

which potential complication may occur early in the recovery period when providing care for a client with paraplegia secondary to a spinal cord injury? a. impairment of bladder control b. inadequacy of nutritional intake c. insufficient quadriceps setting d. unskillful use of aids for ambulation

a. impairment of bladder control

Which assessment is priority after checking airway for a client with a cervical spinal cord injury? a. level of consciousness b. sensory perception in all extremities c. presence and location of diaphoresis d. vital sign assessment and oxygen assessment

a. level of consciousness

a client, readmitted for exacerbation of ulcerative colitis, is weak, thin, and irritable. the client states, "i am now ready for the surgery to create an ileostomy." which nursing intervention best meets the clients needs at this time? a. parenterally replace the clients fluids and electrolytes b. adjust the clients diet to promote weight gain c. provide anticipatory teaching on the use of ileostomy appliances d. encourage the client interaction with other clients who has an ileostomy

a. parenterally replace the clients fluids and electrolytes

Which intervention would the nurse preform first for the client admitted with a closed head injury and increased ICP? a. place the head and neck in neutral alignment b. obtain a prescription for 100 mg of pentobarbitol IV c. administer 1 g mannitol IC as prescribed d. increase the ventilators respiratory rate to 20 breaths/ min

a. place the head and neck in neutral alignment

which assessments are the most significant for a client who is believed to have myasthenia gravis? a. capacity to smile and close the eyelids b. ability to check and speak words distinctly c. effectiveness of respiratory exchange and ability to swallow d. degree of anxiety and concern about the suspected diagnosis

c. effectiveness of respiratory exchange and ability to swallow

In which position would a nurse maintain a client who has experienced a subarachnoid hemorrhage? a. supine b. on the unaffected side c. in bed with the HOB elevated d. with sandbags on either side of the bed

c. in bed with the HOB elevated

which information would the nurse consider when planning care for a group of clients with myasthenia gravis, Gullian-barre syndrome, and ALS? a. progressive deterioration until death b. deficiencies of essential neurotransmitters c. increased risk for respiratory complications d. involuntary twitching of small muscle groups

c. increased risk for respiratory complications

Which intervention is the appropriate initial nursing action when a client reports urinary urgency and frequency during an exacerbation of MS? a. begin teaching self-catheterization b. develop a plan to ensure high fluid intake c. palpate the suprapubic area of the abdomen d. initiate a regimen to monitor urinary output

c. palpate the suprapubic area of the abdomen

Which rationale explains why fluid intake would be increased for a client who has quadriparesis from a spinal cord injury? a. to maintain dehydration b. to maintain electrolyte imbalances c. to prevent a urinary tract infection d. to limit an increase in temperature

c. to prevent a urinary tract infection

the assessment of a newly admitted client reveals malnourishment, nausea, distension, and a firm abdomen w/ ascites. the client has tachycardia and is hypotensive. which physiological change occurred that resulted in the clients development of ascites? a. an increase in vitamin to maintain cell coenzyme function b. an increase in iron to maintain adequate hemoglobin synthesis c. a decrease in sodium to maintain its concentration in tissue fluid d. a decrease in plasma protein to maintain adequate capillary -tissue circulation

d. a decrease in plasma protein to maintain adequate capillary -tissue circulation

Which clinical finding is consistent with an increase in ICP? a. thready, weak pulse b. narrowing pulse pressure c. regular, shallow breathing d. lowered level of consciousness

d. lowered level of consciousness rationale: altered consciousness is the first sign of increased ICP

Which action would the nurse take when a client complains of a headache and drowsiness after an automobile collision while being oriented to person and placed but confused on time with pupils equal and reactive? a. keep the client in the supine position b. prepare the client for mannitol administration c. stimulate the client to maintain responsiveness d. monitor the client for increasing ICP

d. monitor the client for increasing ICP

the serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. which is an important nursing intervention? a. weight the client daily b. restrict the clients oral fluid intake c. measure the clients urine specific gravity d. observe the client for increasing confusion

d. observe the client for increasing confusion

which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the ED to a neurological trauma unit? a. notify the receiving unit of the transfer b. having the clients record ready for the transfer c. verifying that the family has been notified of the transfer d. validating availability of bag-valve mask during the transfer

d. validating availability of bag-valve mask during the transfer

s/s of herniation with increased ICP:

*Cushing's triad*: -bradycardia -HTN -irregular respirations

Lab s and dx testing for peritonitis:

*abdominal paracentesis fluid collection --> C&S* -post procedure patients should have improved respiratory function, decreased wt, and improved vascular status/ perfusion CT scan Abdominal ultrasound CBC --> neutrophils will be elevated CMP --> K, Na, BUN, Cr, glucose ESR & CRP

Causes of MS:

-immune -genetics --> females -infectious factors -environmental factors

*Late s/s of increase intracranial pressure (ICP):*

Cushing's triad: -bradycardia -irregular respirations -HTN -patient will need immediate intervention or they can herniate their brain stem Decorticate positioning --> abnormal flexion in response to stimulus Decebrate positioning --> abnormal extension in response to stimulus

a client has a MAP of 97 and an intracranial pressure of 12. calculate the cerebral perfusion pressure for this client:

85 CPP = MAP -ICP

Traumatic brain injury:

A non-neurodegenerative damage to the brain from an external force leads to temporary or permanent neurological changes Can be direct, indirect, blunt, penetrating, open, or closed

Non-surgical treatment for peritonitis:

Treat the underlying cause: -change peritoneal dialysis to hemodialysis -surgical repair for rupture/ appendicitis -antibiotic for spontaneous like pancreatitis and cirrhosis -exploratory laparotomy is the cause is unknown

Forces of a traumatic brain injury:

Acceleration injury -external force contracting the head -suddenly places the head in motion Deceleration injury: -moving head is suddenly stopped -the head hits a stationary object Rational: -side to side or twisting motion resulting in a shearing motion -more than one are is impacted --> potentially the whole brain Diffuse axonal injury: -results in a very significant brain injury -the brain shear over itself because the force was so significant -neurons die and the residual death of neurons causes increased ICP

Assessment findings for spinal cord injuries:

Depends on the location of the spinal cord injury Cognition changes: -usually cervical spinal cord injuries -we can use the glawgow coma scale to measure eye opening, motor response, and verbal response -highest possible score is 15 --> score of 8 we need to intubate Motor changes: -tetraplegia/ quadriplegia --> all 4 extremities are paralyzed -quadriparesis --> all 4 extremities are weak -paraplegia --> 2 extremities are paralyzed -paraparesis --> 2 extremities are weak Sensory changes: -hypoesthesia --> decreased sensation -hyperesthesia --> increases sensation, common in partial/incomplete spinal cord injuries Cardiovascular: -systolic BP <90 must be treated --> we want to make sure that the intact part of the spinal cord receives the blood it needs Respiratory: -spinal cord injuries place patients at risk for respiratory failure or depression -pneumonia can develop because patients with spinal injuries cant cough as strongly GI: -spinal cord injuries put pts at risk for a paralytic ileus GU: -patients are at risk for urinary retention -neurogenic bladder may develop and patients will lose the ability to urinate themselves

Labs for cirrhosis:

ELEVATED: -AST (normal: 0-35) -ALT (normal: 4-36) -ALK phos (alkaline phosphatase) -ammonia -bilirubin -PT & INR (because the liver is the organ that makes clotting factors) --> BLEEDING PRECAUTIONS (normal PT: 11-12.5) (normal INR: 0.8-1.1) DECREASED: -albumin -protein

Dx testing for gullian barre syndrome (GBS):

Electromyography -tiny needles are placed into the muscles to sense if there are any nerve signals Lumbar puncture: -patients either need to be in the orthopneic position or lying on their side in a fetal position for this procedure -once the procedure is completed the client must lie flat on their back for several hours because lumbar punctures can cause significant spinal headaches -if they have gillian barre syndrome the results will come back normal (the lumbar puncture is used to rule out the underlying cause of GBS)

Treatment for MS:

Immunomodulators: -biological agents -IVIG -Interferon --> a protein Anti-inflammatory --> corticosteroids (usually used during exacerbation) Symptom management: -muscle relaxants --> baclofen/ cyclobensoprin -cannabis

Dx testing for MS:

MRI --> gold standard for diagnosis -there has to be a presence of plaques in at least 2 areas of the brain

Nursing interventions for spinal cord injuries:

Maintain spine immobilization and stabilization -assist with passive ROM -DVT prophylaxis -Priority --> Asses respiratory system and function -Monitor and trend VS --> we will be able to determine if autonomic dysreflexia is happening -Assess motor function and sensory levels -Assess pain -Monitor intake and output as well as weights -Monitor surgical site and pin sites -Patient education

Treatment for myasthenia gravis:

Medical: -anticholinestrase medications --> keeps cholinestrase from being broken down -helps to manage symptoms -neostigmine -prridostigmine -these are time sensitive meds and need to be given before they eat -plasmapheresis w/ IVIG --> done every few weeks to months Surgical: -thymectomy --> only done when myasthenia gravis is very significant

Non-surgical treatment for chron's:

Medications: -glucocorticoids --> short term -antidiarrheals --> use with caution -immunomudulators/ biologics -monoclonal antibodies -ciprofloxacin and metronidazole --> if infection is present -blood transfusions PRBCs if anemia is indicated by low H&H Diet: -avoid caffeine, alcohol, raw produce, high fiber foods, lactose, carbonated beverages, nuts, and dried fruits -TPN / NPO (if bowel rest is needed) -enteral nutrition (if bowel rest isnt needed)

Treatment for gillian barre syndrome (GBS):

Medications: -intravenous immunoglobin (IVIG) --> antibodies that are infused into the client to take over the immune system and stop/ decrease the progression of the disease -corticosteroids -analgesics Plasmapheresis: -antigens are filtered out of the blood to get rid of the antigen causing GBS -Complications --> at risk for clots (they typically will be receiving heparin)

TPN and PPN:

Nutrition delivered via the vascular system bypass the GI tract Indications for TPN/ PPN: -inadequate absorption resulting from short bowel syndrome -GI fistula -bowel obstruction -prolonged bowel or GI rest -severe malnutrition -other disease states of conditions in which oral or enteral feeding are not an option -burns --> hypermetabolic demand -pancreatitis

Nursing interventions for acute pancreatitis:

Pain management -fetal position for comfort -mild pancreatitis (2-3 days of increased pain) -severe pancreatitis (2-3 wks of increased pain) *Maintain NPO* -hydration -monitor respiratory status

Non-surgical treatment for chronic pancreatitis:

Pancreatic enzyme replacement therapy (PERT): -a combination of amylase, lipase, and protease -DO NOT chew -must be taken with all meals and snacks -must take a PPI or H2 antagonist when taking PERT because gastric acid destroys lipase Nutrition: -*encourage them to eat small bland meals --> we dont want them to be NPO* -need 4-6,000 calories/ day -diet high in protein and carbs -these patients are good candidates for TPN d/t their high caloric demand -avoid foods high in fat and avoid alcohol

PPN:

Partial parenteral nutrition -can go through PIVCs or midlines -is less concentrated than TPN so its less likely to cause vein irritation

Peritonitis bacterial risk factors:

Perforation: -appendicitis -diverticulitis -peptic ulcer -external penetrating wound -gangrenous gallbladder -bowel obstruction -ascending genital infection (chlamydia/ pelvic inflammatory dz) -invasive tumor -surgical leakage -peritoneal dialysis

Portal HTN:

Persistent increases pressure in the portal vein d/t obstruction -the obstruction is the enlarged liver (hepatomegaly) -patients will have increased cardiac output d/t increased volume

Primary vs. secondary traumatic brain injuries:

Primary: actual cause of the injury Secondary: results from an injury that can cause secondary brain injury -cerebral edema --> because it increases ICP -ischemia -hypoxia -infection -endocrine changes

Chronic pancreatitis

Progressive, permanent and irreversible -times of remissions and exacerbations of inflammation causes fibrosis and tissue destruction

Nursing interventions for myasthenia gravis

Safety Focused cardiovascular assessment: -if parasympathetic nervous system is blocked they can be tachycardic -if on an anticholinestrase --> they can be bradycardic Focused neuromuscular assessment Monitor nutritional intake and I & O's: -decrease the risk for aspiration (monitor LS) -larger meals in the morning --> these patients become too tired to eat later in the day -breakfast and lunch are their best meals -weekly weights -eat within 1 hr of taking anticholinestrase --> they will be less likely to aspirate -advocate for SLP referral Decrease risk for exacerbation: -exacerbations occur when they are sick and the immune system is impacted -advocate for these patients to get the flu and pneumonia vaccine -avoid crowds/ individuals with illness/ fatigue/ excessive exertion Med education and effectiveness

Potential complications of traumatic brain injuries:

Seizures: -if the patient is actively having a seizure give a benzodiazepine Cognition, mood, or behavior changes increased risk for DVT/ PE SIADH or DI -SI = increase in antidiuretic hormone causing retention of fluid -DI = decrease in antidiuretic hormone causing a loss of fluid and the patient will be dehydrated Hypotension Hypoxia Increased ICP -hydrocephalus -intracranial hemorrhage if there's an intracranial fracture (subdural hematoma or subarachnoid hemorrhage)

Neurogenic shock:

Systemic vasodilation occurs within the 1st 30 minutes of a spinal cord injury -patients will go from the initial stage of shock to the refractory -S/S --> hypotension, bradycardia, irregular temp 1st line treatment: -*fluid resuscitation* -if fluid does not bring BP up vasopressors should be initiated (MAP goal for these patients is 85-90 to enhance blood flow to the spinal cord and prevent further damage)

Potential complications of cirrhosis:

We want to manage the complications the patient has -portal HTN -ascites -esophageal varices and gastric varices -splenomegaly -hepatic encephalopathy -hepatorenal syndrome -hepatopulmonary -peritontis

the nurse provides education for a client with cirrhosis of the liver who has a prolonged prothrombin time and low platelet count. a regular diet is prescribed. which instruction would the nurse include in the teaching? a. avoid foods high in phytonadione b. check the pulse several times a day c. drink a glass of milk when taking aspirin d. report signs of bleeding no matter how slight

d. report signs of bleeding no matter how slight

An LPN/ LVN under the RN's supervision is assigned to provide nursing care for a patient with Gillian Barre syndrome (GBS). What observation should the LPN/LVN be instructed to report immediately? a. reports of numbness and tingling b. facial weakness and difficulty speaking c. rapid HR of 102 beats/min d. shallow respirations and decreased breath sounds

d. shallow respirations and decreased breath sounds

Complete spinal cord injury:

results in no function or feeling below the injury