Med Surg Quiz 3
Which is most important to ask when obtaining a developmental history of someone with seizures? A. Childhood injuries B. Adult injuries C. Illnesses D. Pregnancy
All of them are important to ask during a developmental history
A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture?
An area of ecchymosis (bruising) may be seen over the mastoid (Battle sign) in a basilar skull fracture. Basilar skull fractures are also suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).
The patient is having a seizure you should: A. Clean up his stool while he is seizing to preserve dignity B.tell all family members to leave politely C. Assess corneal flexibility D. Uncover the patient who asks you to preserve his modesty
D. You need to be assess all paints body parts involved. Corneal relfexity is not a thing; you should just be looking to see if the eyes are open or if the eyes and head are turned to one side
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?
Lung auscultation and measurement of vital capacity and tidal volume In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis.
The most important nursing priority of treatment for a patient with an altered LOC is to:
Maintain a clear airway to ensure adequate ventilation.
WHen do symptoms of a chronic subdural hematoma develop?
Mostly r/t brain atrophy that occurs with aging
hich condition occurs when blood collects between the dura mater and arachnoid membrane?
Subdural hematoma
What happens when there is a high cervical spine injury?
Tetraplegia-paralysis of all extremities
A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client
Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.
A nurse knows that the symptoms of an acute hematoma develop over how many days and include?
1-2 days. LOC, pupillary signs, loss of feeling on one side of the body, and coma based on blood accumulation.
When do symptoms of a subacute subdural hematoma develop?
2 days to two weeks
You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?
Autonomic dysreflexia Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides.
While providing education your patient asks you what the MRI will be him about his seizures? You tell him: A: the MRI is useful in identifying epileptogenic zone in the brain B: the MRI detects structural lesions C: the MRI assists in identifying they type of seizure that has occurred.
B. The MRI detects structural lesions like cerebral dengenerative changes, focal abnormalities, and CBV abnormalities.
As an RN what would you be most concerned with, for a patient having a seizure: A. The aura B. The patients prior seizure history C. The patient broccili he was eating right before the seizure
C. AIRWAY patient may be choking and seizing!
In trying to determine which epileptogenic zone is causing a patients seizure which test do you expect? A.MRI B. EEG C. SPECT
C. Spect
The patient asks you what an EEG does besides assiting in identifying which type of seizure that has occured? You reply: A. Hematologic, serologic, and biochemical tests. B. Prior seizures that have happened C. If the abnormalities continue between seizure activity.
C. The EEG assists in identifying which type of seizure has occured as well as if the abnormalities continue after the seizure has stopped.
Which examinations should a nurse complete in addition to a head to toe physical and neuro exam? A. Blood disorder tests B. Tests to determine antibodies in the serum C. Acidase and Monconkay agar test D. all of the above
D. All of the above in addition to a neuro and physical exam the nurse should collect hematologic, serologic, and biochemical tests.
A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?
Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.
A 67 yr old M patient is in the hospital. While taking his vitals he loses conciousness with a 20 Second lasting body stiffness w/ moaning, apnea, and is foaming from the mouth. What is the most accurate label of seizure does the nurse suspect to tell the doctor?
Generalized Tonic Seizure
A child gets smacked in the head with a watermelon. When you ask him what his name is he says "Carlos" but his name is clearly Steve. You continue to ask him questions until his confusion resolves after about 13 minutes. What grade concussion will you report to the EMT after the ambulance arrives?
Grade 1
While working as a nurse for a highschool football game, a child gets hit on the head and loses conciousness for 5 minutes before the ambulence arrives. What grade concussion will the nurse report to the EMT?
Grade 3
The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures?
Immediately after a SCI, a paralytic ileus usually develops. A nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration.
The patient wants to know why we document his gaze, stiffness, and position of his head before he has a seziure?
It helps to identify the location of the seizure
The nurse received the report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?
Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal.
What happens with injuries at the thoracic level?
Paraplegia-inability to feel lower half of body
Decerebate Posturing
The result of lesions at the midbrainand is more ominous than decorticate posturing. The posturing results from cerebral trauma and is not normal. THe patient has no motor function, is limp, and lacks motor tone with flaccid posturing.
A 19 yr old F present to the clinic with acute loss of vision and after taking her vitals she begins to see again. She asks you why she lost her vision? What is your reply:
There is a high possiblity you have experienced a focal (occipital region) onset aware seizure because you remember what happened and there were no motor symptoms and the event took place in less than 2 minutes.
What are the three cardinal signs of brain death?
coma, absence of brain stem reflexes, and apnea.
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?
ecause a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation.
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?
ntracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries).
A nurse knows that a person who cannot feel the lower half of his body has:
paraplegia
