MS3 exam 1 review

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Left visual field deficit

The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what?

A lower motor neuron lesion

A nurse caring for a client who has hemophilia is getting ready to take the client's vital signs. What should the nurse do before taking a blood pressure?

Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints.

A patient describes numbness in the arms and hands with a tingling sensation. The patient also frequently stumbles when walking. What vitamin deficiency does the nurse determine may cause some of these symptoms?

B12

A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurses primary assessment focus?

Cardiac and respiratory status

The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of risk for impaired skin integrity. How can the nurse best address this risk?

Change the patients position frequently.

A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care?

Difficulty in coordination

A client with megaloblastic anemia reports mouth and tongue soreness. What instruction will the nurse give the client regarding eating while managing the client's symptoms?

Eat small amounts of bland, soft foods frequently."

A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death?

Electroencephalography (EEG)

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness

What type of anemia results from red blood cell destruction

Hemolytic

A nurse provides nutritional information for a patient diagnosed with an iron-deficiency anemia. What education should the nurse provide?

Increase the intake of green, leafy vegetables.

An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy?

International normalized ratio greater than 2

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?

Lack of deep tendon reflexes

The nurse is assessing a new patient with complaints of overwhelming fatigue and a sore tongue that is visibly smooth and beefy red. This patient is demonstrating signs and symptoms associated with what form of what hematologic disorder?

Megaloblastic anemia

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord?

Multiple sclerosis

A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform?

Position the patient upright during feeding.

A patient with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action?

Positioning the patient with the head of the bed elevated 45 degrees

The nurse is performing an initial assessment on a client who is admitted to rule out myasthenia gravis. Which of the following findings would the nurse expect to observe?

Ptosis and diplopia

Which of the following is the first-line therapy for myasthenia gravis (MG)?

Pyridostigmine bromide (Mestinon)

The nurse obtains a unit of blood for the client, Donald D. Smith. The name on the label on the unit of blood reads Donald A. Smith. All the other identifiers are correct. What action should the nurse take?

Refuse to administer the blood

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:

Right-sided paralysis.

Fresh-frozen plasma (FFP) has been ordered for a hospital patient. Prior to administration of this blood product, the nurse should prioritize what patient education?

Signs and symptoms of a transfusion reaction

Which is indicative of a right hemisphere stroke?

Spatial-perceptual deficits

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?

Speeds nerve impulse transmission

A nurse is admitting a patient with immune thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that potentially alter platelet function? Select all that apply.

Sulfa-containing medications Aspirin-based drugs NSAIDs

acute hemolytic reaction s/s

Symptoms consist of fever, chills, low back pain, nausea, chest tightness, dyspnea, and anxiety As the erythrocytes are destroyed, the hemoglobin is released from the cells and excreted by the kidneys; therefore, hemoglobin appears in the urine (hemoglobinuria). Hypotension, bronchospasm, and vascular collapse may result. Diminished renal perfusion results in acute kidney injury, and disseminated intravascular coagulation may also occur

A patient is scheduled for a splenectomy. During discharge education, what teaching point should the nurse prioritize?

The need to report any signs or symptoms of infection promptly

A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant?

Uneven, labored respirations

A patient is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications?

Vitamin B12

A patient is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the patient in preparation for this test?

You will need to lie still throughout the procedure.

ICP

a computed tomography (CT) of the head or magnetic resonance imaging (MRI) can reveal signs of raised ICP Hemorrhagic stroke can cause ICP which is treated by drainaged. Mannitol may be administered to reduce ICP. Elevating the head of the bed to 30-45 degrees, avoidance of hyperglycemia and hypoglycemia, sedation, and use of hypertonic saline in a variety of concentrations hyperthermia raise in BP =ICP

The most common cause of iron deficiency anemia in men and postmenopausal women is

bleeding

what causes Guillain-Barr, triggered by something

vial infection (flu, pneumonia)

The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms? Select all that apply.

· Demonstrate daily muscle stretching exercises. · Apply warm compresses to the affected areas. · Allow the patient adequate time to perform exercises

The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?

"Have you experienced any viral infections in the last month?"

The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education?

"I will stretch daily as directed by the physical therapist."

hemophilia factors

(8 or 9) Recombinant forms of factor VIII and IX concentrates are available and decrease the need for using plasma-derived factor concentrates and fresh-frozen plasma. Concentrates are used when patients are actively bleeding; it is important that treatment is initiated as soon as possible to reduce risk for bleeding complications. Factors should be administered prophylactically prior to traumatic procedures to prevent excessive bleeding

Read abt Splenectomy and patient care afterwards, discharge instructions, lab work especially when looking at neutrophils and band cells and what they mean

(left shift in band cells=band cells are immature neutrophils that only get released when needed bc infection growing)

Allergic reactions

(normally expected and why we give Benadryl) Some patients develop urticaria (hives) or generalized itching during a transfusion; the cause is thought to be a sensitivity reaction to a plasma protein within the blood component being transfused The reactions are usually mild and respond to antihistamines. These reactions are managed with epinephrine, corticosteroids, and vasopressor support, if necessary.

Right side stroke s/s:

- Paralysis or weakness on left side of body - Left visual field deficit - Spatial-perceptual deficits - Increased distractibility - Impulsive behavior and poor judgment -Lack of awareness of deficits

focus on blood transfusions, need to know what to do in case of reaction (first step is to stop transfusion)

-Stop the transfusion. Maintain the IV line with normal saline solution through new IV tubing, given at a slow rate. -Assess the patient carefully. Compare the vital signs with baseline, including oxygen saturation. Assess the patient's respiratory status carefully. Note the presence of adventitious breath sounds; the use of accessory muscles; the extent of dyspnea; and changes in mental status, including anxiety and confusion. Note any chills, diaphoresis, jugular vein distention, and reports of back pain or urticaria. -Notify the primary provider of the assessment findings and implement any treatments prescribed. Continue to monitor the patient's vital signs and respiratory, cardiovascular, and renal status. -Notify the blood bank that a suspected transfusion reaction has occurred. -Send the blood container and tubing to the blood bank for repeat typing and culture. The patient's identity and blood component identifying tags and numbers are verified.

Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, would not be manifested by which of the following?

20/20 vision

A client admitted with meningitis is to receive Vancocin (vancomycin) 250 mg in 100 mL intravenously over 60 minutes twice a day. The IV tubing set is calibrated at 15 drops per/mL. At how many drops per minute will the nurse run this solution? Enter the correct number ONLY.

25

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?

3 hours

The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg/kg t-PA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?

5.4

A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially?

6.3

A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the health care provider immediately because the client probably is experiencing which problem?

A hemolytic allergic reaction caused by an antigen reaction

Autologous donation

A patient's own blood may be collected for future transfusion; this method is useful for many elective surgeries where the potential need for transfusion is high (e.g., orthopedic surgery). Preoperative donations are ideally collected 4 to 6 weeks before surgery. Iron supplements are prescribed during this period to prevent depletion of iron stores. Typically, 1 unit of blood is drawn each week; the number of units obtained varies with the type of surgical procedure to be performed

A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?

Absence of reflexes along with flaccid extremities

In myasthenia gravis (MG), there is a decrease in the number of receptor sites of which neurotransmitter?

Acetylcholine

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?

Administer atropine to control the side effects of edrophonium.

9. Paramedics have brought an intubated patient to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?

Administer benzodiazepines on a PRN basis benzodiazepines are the most commonly used sedatives and do not affect cerebral blood flow or ICP

The nurse is talking with the parents of a toddler who was diagnosed with hemophilia A. What instruction should the nurse give to the parents?

Administer factor VIII intravenously at the first sign of bleeding

When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware?

Alteration in level of consciousness (LOC)

The nurse is advising a client with multiple sclerosis on methods to minimize spasticity and contractures. Which of the following techniques would the nurse instruct the client to perform?

Apply warm packs to the affected area.

The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the patients level of consciousness (LOC)?

Assess the patients eye opening and response to stimuli.

A patients low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform?

Assess the patients vital signs to establish baselines

Which nursing intervention is the priority for a client in myasthenic crisis?

Assessing respiratory effort

The nurse is conducting a focused neurologic assessment. When assessing the patients cranial nerve function, the nurse would include which of the following assessments?

Assessment of gag reflex

Directed donation

At times, friends and family of a patient wish to donate blood for that person. These donations are not any safer than those provided by random donors, because directed donors may not be as willing to identify themselves as having a history of any of the risk factors that disqualify a person from donating blood.

Which of the following, if left untreated, can lead to an ischemic stroke?

Atrial fibrillation

A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client?

Auditory agnosia

The nurse caring for a patient in ICU diagnosed with Guillain-Barr syndrome should prioritize monitoring for what potential complication?

Autonomic dysfunction

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?

Avoid hot baths and showers.

A nurse is providing discharge education to a patient who has recently been diagnosed with a bleeding disorder. What topic should the nurse prioritize when teaching this patient?

Avoiding activities that carry a risk for injury

An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction?

Be vigilant in identifying the patient and the blood component.

A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron-deficiency anemia in recent weeks. When providing the patient with nutritional guidelines and meal suggestions, what foods would be most likely to increase the womans iron stores?

Beef liver accompanied by orange juice

A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patients cardiac and neurologic status, the nurse monitors the patient for signs of what complication?

Bleeding

Which of the following is the most common side effect of tissue plasminogen activator (tPA)?

Bleeding

A client is following up after a visit to the emergency department where testing indicated that the client had suffered a transient ischemic attack. What lifestyle changes would the nurse include in teaching to prevent further reoccurrence? Select all that apply.

Blood pressure control Weight loss Smoking cessation

A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS?

Blurred vision, intention tremor, and urinary hesitancy

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?

Bradycardia and hypertension

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following?

Cardiogenic emboli

When dealing w pt w neurological disorder or any kind of paralysis and aren't able to really move in bed, focus on taking care of their skin- know ways to do that

Change the patients position frequently.

A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first?

Check the patients indwelling urinary catheter for kinks to ensure patency.

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?

Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."

A client is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met?

Closely monitor intake and output.

A patient is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met?

Closely monitor intake and output.

A night nurse is reviewing the next days medication administration record (MAR) of a patient who has hemophilia. The nurse notes that the MAR specifies both oral and subcutaneous options for the administration of a PRN antiemetic. What is the nurses best action?

Contact the prescriber to have the subcutaneous option discontinued.

The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions?

Dilute the liquid preparation with another liquid such as juice and drink with a straw.

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?

Diplopia and ptosis

A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurses most appropriate action?

Discontinue the remainder of the PRBC transfusion and inform the physician.

A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurses priority action?

Discontinue the transfusion

During the performance of the Romberg test, the nurse observes that the patient sways slightly. What is the nurses most appropriate action?

Document successful completion of the assessment.

The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption?

Eating calf's liver with a glass of orange juice

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?

Edrophonium (Tensilon)

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?

Elevating the head of the bed to 30 degrees

When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal?

Elevation of the head of the bed

The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action?

Ensure atropine is readily available.

Pt with MS what should you keep at bedside

Ensure that suction apparatus is set up at the bedside.

he nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patients safety, what nursing action should be performed?

Ensure that suction apparatus is set up at the bedside.

The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia?

Erythrocytes that are microcytic and hypochromic

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?

Every 15 minutes

10. The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?

Facial droop

multiple sclerosis MS s/s

Fatigue Depression Weakness Numbness Difficulty in coordination Loss of balance Spasticity - she spoke on this Pain Diplopia - seeing double

An adult patient has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this patients health status?

Fatigue related to decreased oxygen-carrying capacity

A teenaged client with hemophilia sustains a leg laceration after falling off a skateboard and is brought to the emergency department. The laceration is bleeding profusely even with direct pressure to the site. What does the nurse anticipate will be prescribed for administration to control bleeding?

Fresh frozen plasma

A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intravenously. The nurse is careful to assess which of the following related to intake of nutrients?

Gag reflex and bowel sounds

The nurse is teaching a patient with Guillain-Barr syndrome about the disease. The patient asks how he can ever recover if demyelination of his nerves is occurring. What would be the nurses best response?

Guillain-Barr spares the Schwann cell, which allows for remyelination in the recovery phase of the disease.

A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis?

Help the client perform range-of-motion (ROM) exercises every 8 hours.

A patients electronic health record states that the patient receives regular transfusions of factor IX. The nurse would be justified in suspecting that this patient has what diagnosis?

Hemophilia

The results of a patients most recent blood work and physical assessment are suggestive of immune thrombocytopenic purpura (ITP). This patient should undergo testing for which of the following potential causes? Select all that apply.

Hepatitis HIV

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:

Hypertension

he nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?

Hyperthermia

Which of the following describes a red blood cell (RBC) that has pale or lighter cellular contents?

Hypochromic

The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?

I have difficulty breathing when walking 30 feet."

After teaching a client about taking daily oral iron preparations for a moderate iron deficiency anemia, which statement by the client indicates to the nurse that additional instruction is needed?

I will call the doctor if my stools turn black."

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?

I will receive parenteral vitamin B12 therapy for the rest of my life."

Nursing Interventions/ Patient education on CT

If contrast is being used, the patient must be assessed for any iodine/shellfish allergies before the CT. - kidney function should be evaluated -educating the patient on the need to lay quietly during the procedure.

A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. What nursing diagnosis is most likely for a patient with this condition?

Impaired verbal communication

A nurse is a long-term care facility is admitting a new resident who has a bleeding disorder. When planning this residents care, the nurse should include which of the following?

Implementing of a plan for fall prevention

A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this patient?

In the morning, with frequent rest periods

You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a therapeutic benefit of this medication?

Increased muscle strength

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

Increased urine output

The nurse on the pediatric unit is caring for a 10-year-old boy with a diagnosis of hemophilia. The nurse knows that a priority nursing diagnosis for a patient with hemophilia is what?

Ineffective coping

A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke?

Intracerebral hemorrhage

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?

Intracranial hemorrhage

A patient comes to the clinic complaining of fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the patient will be diagnosed?

Iron deficiency anemia

A nurse is providing education to a patient with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education?

Iron will cause the stools to darken in color.

A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?

Limited attention span and forgetfulness

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?

Lioresal (Baclofen)

During the review of morning laboratory values for a client reporting severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which finding?

Low ferritin level concentration

A patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests?

Lumbar puncture

The nurse is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient?

MS is a progressive demyelinating disease of the nervous system

The diagnosis of multiple sclerosis is based on which test?

Magnetic resonance imaging

Which of the following is accurate regarding a hemorrhagic stroke?

Main presenting symptom is an "exploding headache."

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important?

Maintaining a patent airway

The nurse is planning care for a client with Guillain-Barre syndrome. The priority client outcome would be which of the following?

Maintains effective respirations and airway clearance

know goal of treatment for MG

Management of myasthenia gravis is directed at improving function and reducing and removing circulating antibodies. Therapeutic modalities include administration of anticholinesterase medications and immunosuppressive therapy, intravenous immune globulin (IVIG), therapeutic plasma exchange, and thymectomy

MG s/s

Manifestations- -Initially symptoms involve ocular muscles; diplopia and ptosis -Weakness of facial muscles, swallowing and voice impairment (dysphonia), generalized weakness The clinical manifestation of myasthenia gravis is highly variable. There are two clinical types: ocular and generalized. In the ocular form, only the eye muscles are involved. Diplopia (double vision) and ptosis (drooping of the eyelids) are common In the generalized form, patients experience weakness of the muscles of the face and throat (bulbar symptoms), limbs, and respiratory weakness. Weakness of the facial muscles results in a bland facial expression. Laryngeal involvement produces dysphonia (voice impairment) and dysphagia (difficulty swallowing), which increases the risk of choking and aspiration. Generalized weakness affects all extremities and may involve the intercostal muscles, resulting in decreasing vital capacity and respiratory failure. When this occurs, the patient is in a myasthenic crisis

Which of the following is considered a central nervous system (CNS) disorder?

Multiple sclerosis

A nurse is planning the care of a patient who has a diagnosis of hemophilia A. When addressing the nursing diagnosis of Acute Pain Related to Joint Hemorrhage, what principle should guide the nurses choice of interventions?

NSAIDs are contraindicated due to the risk for bleeding.

A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply.

Neglect of objects and people on the left side. Left-sided hemiplegia. Tendency to distractibility

A client with a diagnosis of pernicious anemia comes to the clinic reporting of numbness and tingling in his arms and legs. What do these symptoms indicate?

Neurologic involvement

A patient diagnosed with multiple sclerosis (MS) has ataxia. Which of the following medications could be used to treat this clinical manifestation?

Neurontin

A transcranial Doppler ultrasonography detects cerebral vasospasms in a client experiencing lethargy 8 days following a subarachnoid hemorrhage. The nurse anticipates which therapeutic intervention?

Nimodipine PO

vasospasm medication

Nimodipine is the most studied calcium channel blocker for prevention of vasospasm in subarachnoid hemorrhage

A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke?

Noncontrast computed tomography

The nurse, caring for a client in the emergency room with a severe nosebleed, becomes concerned when the client asks for a bedpan. The nurse documents the stool as loose, tarry, and black looking. The nurse suspects the client may have thrombocytopenia. What should be the nurse's priority action?

Notify the physician

A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply.

Orthostatic hypotension Autonomic dysreflexia DVT

The nurse's role in the management of polycythemia vera is primarily that of an educator. Choose the best health promotion advice that a nurse could give.

Participate in regular phlebotomy procedures to decrease blood viscosity

Know when pt has bleeding disorders, pt education you would give them/ pt safety info

Patients with bleeding disorders need to understand the importance of avoiding activities that increase the risk of bleeding, such as contact sports. A donor who appears pale or complains of faintness should immediately lie down or sit with the head lowered below the knees. The donor should be observed for another 30 minutes. If a family history or personal risk is suspected, the person should be carefully screened for bleeding disorders prior to surgical procedures. Nursing management: limit injury, assess for bleeding, bleeding precautions bleeding disorder- failure of hemostatic mechanisms

Know about what condition would require a patient to do a therapeutic phlebotomy (therapeutic phlebotomy is when they have to remove blood from the patient bc they have too many RBCs)

Patients with elevated hematocrits ( those with polycythemia vera) or excessive iron absorption (hemochromatosis) can usually be managed by removing one unit (abt 500 mL) of whole blood

The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI?

Perform passive ROM exercises as ordered.

Standard donation

Phlebotomy consists of venipuncture and blood withdrawal. Standard precautions are used skin is carefully cleansed with an antiseptic preparation, a tourniquet is applied, and venipuncture is performed. Withdrawal of 450 mL of blood usually takes less than 15 minutes.

A nurse should expect to administer which vaccine to the client after a splenectomy?

Pneumovax 23

The patient in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a post-lumbar puncture headache, what is the nurses most appropriate action?

Position the patient prone.

The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly patients with MS are known to be particularly concerned about what variables? Select all that apply.

Possible nursing home placement Becoming a burden on the family Increasing disability

How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown?

Practice meticulous hygiene measures.

The critical care nurse is admitting a patient in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this patient?

Providing ventilatory assistance

A patient diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this patient most likely has?

Relapsing-remitting (RR)

A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions?

Removing all metal-containing objects

A nurse is developing a plan of care for an 85-year-old woman who is bedridden following a stroke. Which of the following would the nurse be least likely to include in the plan of care for this patient to reduce her risk for pressure ulcers?

Repositioning the patient about once a shift

The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest?

Resting in an air-conditioned room whenever possible

The nurse is preparing the patient for a test to determine the cause of vitamin B12 deficiency. The patient will receive a small oral dose of radioactive vitamin B12 followed by a large parenteral dose of nonradioactive vitamin B12. What test is the patient being prepared for?

Schilling test

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?

Semi-Fowler's

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

Severe headache and early change in level of consciousness

The nurses review of a patients most recent blood work reveals a significant increase in the number of band cells. The nurses subsequent assessment should focus on which of the following?

Signs and symptoms of infection

A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurses rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurses most appropriate action?

Slow the infusion rate and monitor the patient closely. exacerbation= discontinue

The nurse has just received report on a client in the ED being transferred to the acute stroke unit with a diagnosis of a right hemispheric stroke. Which findings does the nurse understand is indicative of a right hemispheric stroke?

Spatial-perceptual deficits

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?

Speeds nerve impulse transmission

A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect?

Spinal shock

An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate?

Stool for occult blood

Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?

Tensilon test

know glasgow coma scale, what is purpose, know range of numbers, what they mean (what is severe coma)

The Glasgow Coma Scale is a tool for assessing a patient's response to stimuli. Scores range from 3 (deep coma) to 15 (normal). LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response . -A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. -A score of 15 indicates that the patient is fully responsive

A patient is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this patients adverse reaction?

The donor blood was incompatible with that of the patient.

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

The paralysis caused by this disease is temporary."

Which of the following circumstances would most clearly warrant autologous blood donation?

The patient has elective surgery pending.

A patient is being treated for the effects of a longstanding vitamin B12 deficiency. What aspect of the patients health history would most likely predispose her to this deficiency?

The patient is a vegan.

Nursing Interventions/ Patient education on MRI

The patient is assessed for any implants containing metal, these objects could malfunction, be dislodged, or heat up as they absorb the energy. Cochlear implants will be inactivated by an MRI.

The nurses brief review of a patients electronic health record indicates that the patient regularly undergoes therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible?

The patient may chronically produce excess red blood cells.

A patient for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the patient?

The test may result in dizziness or lightheadedness.

A patient with a recent diagnosis of ITP has asked the nurse why the care team has not chosen to administer platelets, stating, I have low platelets, so why not give me a transfusion of exactly what Im missing? How should the nurse best respond?

Transfused platelets usually arent beneficial because theyre rapidly destroyed in the body.

A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?

Use the smallest needle possible for injections.

The nurse is developing a plan of care for a patient with Guillain-Barr syndrome. Which of the following interventions should the nurse prioritize for this patient?

Using the incentive spirometer as prescribed

The nurse caring for a patient diagnosed with Guillain-Barr syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurses communication with the patient should reflect the possibility of what sign or symptom of the disease?

Vocal paralysis

he nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?

Weakness on one side of the body and difficulty with speech

MG, MS, Guillain-Barr

all these 3 affect respiratory eventually, respiratory failure is risk for those pt, always keep in mind respiratory assessments

Hemophilia A is the most common of the three types of hemophilia. What is diminished in the less serious form of hemophilia A, known as von Willebrand's disease?

amount and quality of factor VIII

Meds for MS (also to treat muscle spasms)

baclofen (Lioresal)

PET scan

causes lightheadedness and dizziness

myasthenia gravis how to prevent myasthenic crisis

cholinergic crisis, education scheduling is important to avoid these medication management is a crucial component of ongoing care. Understanding the actions of the medications and taking them on schedule is emphasized, as are the consequences of delaying medication and the signs and symptoms of myasthenic and cholinergic crises. The patient can determine the best times for daily dosing by keeping a diary to determine fluctuation of symptoms and to learn when the medication is wearing off. The medication schedule can then be manipulated to maximize strength throughout the day. Treatment for myasthenia gravis- know goal of treatment for MG, they have to take it when they feel it wearing off bc it gives them decrease muscle strength, fatigue pyridostigmine bromide (Mestinon) - increase muscle strength

Hemophilia dos and donts pt education

donts: avoid agents that can interfere with platelet aggregation that can add additional risk for bleeding: -Aspirin, NSAIDs, -some herbal and nutritional supplements (e.g., nettle, chamomile) -alcohol -Nasal packing for epistaxis should be avoided because bleeding often resumes when packing is removed -All injections should be avoided; invasive procedures avoided too, perform after given factors - during bleeding episodes avoid heat, may exacerbate bleeding, use cold dos: -Splints and other orthopedic devices may be beneficial in supporting and immobilizing joints and muscles affected by hemorrhage - oral hygiene is important (gigavitis) -wear medical bracelet -family emergency contact info -warm baths can help with pain pt tend to bleed easy so they have to avoid certain sports, strenuous activity bc simple fall can cause bleeding, they bleed in joints (knees, elbows and have to be administered injection pt education on injection)

if stroke suspected

first thing you get is Ct to determine which one, tpa (ischemic) has to be given within 3 hours, but cant give unless you know for fact it is ischemic stroke

Transfusion-Associated Circulatory Overload (TACO):

fluid volume overload (can be life threatening but if caught early enough pt can still continue infusion as long as within 4 hr time limit, blood cannot be given after 4 hours, need to return blood) If too much blood is infused too quickly, hypervolemia can occur. This condition, known as transfusion-associated circulatory overload (TACO), can be aggravated in patients who already have increased circulatory volume (e.g., those with heart failure, renal dysfunction, advanced age, acute myocardial infarction) If the administration rate is sufficiently slow, circulatory overload may be prevented. For patients who are at risk for, or already in, circulatory overload, diuretics are given prior to the transfusion or between units of PRBCs.

A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with left-sided stroke?

impulsive behavior, poor judgment, deficits in left visual fields

The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the following should the nurse include in the patients care plan?

instruct the patient on daily muscle stretching.

The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?

ischemic

A client is receiving mitoxantrone for treatment of secondary progressive multiple sclerosis (MS). This client should be closely monitored for

leukopenia and cardiac toxicity

important steps when giving blood

look at chart in phone -obtain informed consent - prescription for the blood

procedures

need to do assessment and patient history, to see if they have these before procedures if invasive need consent form

Administration times for giving blood

packed rbc 2-4 hr, platelets 15-30...gravity

While assessing a client, the nurse will recognize what as the most obvious sign of anemia?

pallor

MS- know what meds are for exacerbations and what meds are for maintenance

plasmapheresis for a myasthenic exacerbation^^ ch 64 tb ?? IV methylprednisolone, used to treat acute exacerbations, shortens the duration of relapse but has not been found to have long-term benefit bc auto immune disorder will treat w immunosuppresents exacerbations treated w corticosteroids longterm- Interferon beta-1a , Interferon beta- 1b - help prevent relapses of MS can use anti-inflammatories and muscle relaxants avoid triggers such as fatigue- extreme weathers, illness, stress - Drugs used for symptoms Interferon beta-1a Interferon beta- 1b Glatiramer acetate IV methylprednisolone - acute exacerbations Mitoxantrone -Control and exacerbations Baclofen medication for spasticity Benzodiazepines (diazepam), tizanidine, dantrolene used to treat spasticity and improve motor function BB (propranolol, anticonvulsant gabapentin, benzodiazepines (clonazepam) for ataxia (which is the hardest to treat) IV methylprednisolone main drug for exacerbations the others treat the symptoms

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?

severe headache

TPA dosage

tPA dosage and Administration and eligibility- Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in patients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement. The goal is for intravenous (IV) t-PA to be given within 45 minutes of the patient arriving at the ED. Early intervention and recognizing the symptoms of stroke and obtaining appropriate emergency care is necessary to ensure rapid transport to a hospital and initiation of therapy within the recommended 3-hour period (which may be extended up to 4.5 hours). Delays make the patient ineligible for therapies, because revascularization of necrotic tissue (which develops after 3 hours) increases the risk of cerebral edema and hemorrhage. Important remember ischemic stroke get t-PA and you wanna monitor for bleeding on these patients after giving it to them.

Allergic reactions s/s

urticaria (hives), itching, and flushing

At what rate (in drops per minute) should a nurse start an IV infusion if the order is for 1 g of vancomycin (Vancocin) to be given in 180 ml of dextrose 5% in water over 60 minutes? The tubing delivers 15 drops/ml. Enter the correct number only.

45

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?

4:00 p.m.

An intensive care nurse is aware of the need to identify patients who may be at risk of developing disseminated intravascular coagulation (DIC). Which of the following ICU patients most likely faces the highest risk of DIC?

A patient who is being treated for septic shock

The nurse is planning the care of a patient with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this patients health problem is due to what?

Abnormalities in the structure and function RBCs

A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient?

Absolute bed rest in a quiet, nonstimulating environment

A provider prescribes a disease-modifying drug for a patient with relapsing-remitting MS. The nurse advises the patient that the drug has to be taken subcutaneously on a daily basis, and it may take 6 months for evidence of any response. Which of the following is the medication most likely prescribed in this scenario?

Copaxone

A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor?

Decreased level of erythropoietin

The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patients plan of care?

The patient should be placed in a prone position for 15 to 30 minutes several times a day.

A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patients care, what aspect of the patients neurologic and functional status should the nurse consider?

The patient will require full assistance for all aspects of elimination.

A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patients current health status is most likely to have precipitated this event?

The patients urinary catheter became occluded. s/s of autonomic dysreflexia

The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurses best answer?

The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel.

A patient newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the patient asks the nurse to explain the disease. What should the nurse explain to this patient?

There could be decreased production of platelets.

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?

Thirty seconds after administration, the facial weakness and ptosis will be relieved for

Know what positive Romberg sign looks like

test for cerebellar dysfunction that can be done with the patient seated or standing; inability to maintain position for 20 seconds is a positive test The patient can be seated or stand with feet together and arms at the side, first with eyes open and then with both eyes closed for 20 seconds. The examiner stands close to support the standing patient if they begin to fall. Slight swaying is normal, but a loss of balance is abnormal and is considered a positive

A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family?

"The client is unaware of his left side. You should approach him on the right side."

Megaloblastic anemia

-Folic acid deficiency -Vitamin B12 deficiency

A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving:

A-positive blood to an A-negative client.

A patient with Guillain-Barr syndrome has experienced a sharp decline in vital capacity. What is the nurses most appropriate action?

Prepare to assist with intubation.

acute hemolytic reaction

(occurs when blood is incompatible, why we screen to make sure we are giving right blood) The most dangerous, and potentially life-threatening, type of transfusion reaction occurs when the donor blood is incompatible with that of the recipient (i.e., type II hypersensitivity reaction - Largely preventable, common mistakes include blood component labeling, a type of clerical error, and errors in patient identification that result in the administration of an ABO-incompatible transfusion. -Delayed hemolytic reactions usually occur within 14 days after transfusion,

GBS s/s

- Tingling in feet and hands - Symmetric weakness (both sides of body) - Decreased tendon reflexes - Paralysis - Symptoms start at feet and move up on body Manifestations are variable and may include weakness, paralysis, paresthesia, pain, and diminished or absent reflexes, starting with the lower extremities and progressing upward; bulbar weakness; cranial nerve symptoms; tachycardia; bradycardia; hypertension; or hypotension with the most well-known type, the patient experiences weakness in the lower extremities, which progresses upward and has the potential for respiratory failure.

GBS

- is not inherited or last forever... infection?, pt can make full recovery if treated quickly and properly Autoimmune disorder that affects the peripheral nervous system. Causes sudden onset of weakness and paralysis. Pt has viral infection such as influenza or pneumonia that triggers auto immune destruction of myelin sheathe and of the axons in motor and sensory nerves. MS- central NS, GBS- Peripheral NS

Left side stroke s/s:

-Paralysis or weakness on right side of body - Right visual field deficit - Aphasia (expressive, receptive, or global) - Altered intellectual ability - Slow, cautious behavior

A patient diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What should the nurse identify as an expected outcome of this treatment?

Decreased muscle spasms in the lower extremities

After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider?

Diastolic pressure of 110 mm Hg

A nurse is performing a baseline assessment of a client's skin integrity. What are the priority assessments? Select all that apply.

Presence of pressure ulcers on the client Potential areas of pressure ulcer development Overall risk of developing pressure ulcers

A patient undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions?

Prevention of viral infections from another persons blood

Transfusion-Associated Circulatory Overload (TACO) s/s

Signs of circulatory overload include dyspnea, orthopnea, tachycardia, an increase in blood pressure, and sudden anxiety. Jugular vein distention, crackles at the base of the lungs, and hypoxemia will also develop. Pulmonary edema can quickly develop, as manifested by severe dyspnea and coughing of pink, frothy sputum. If fluid overload is mild, the transfusion can often be continued after slowing the rate of infusion and administering diuretic

A patient with Von Willebrand disease (vWD) has experienced recent changes in bowel function that suggest the need for a screening colonoscopy. What intervention should be performed in anticipation of this procedure?

The patient should be given necessary clotting factors before the procedure.

focus on complications of traumatic brain injuries, like diabetes insipidus- can happen if you have any involvement of hypothalamus, what would you do to monitor for that (diabetes insipidus)

A record of daily weights is maintained, especially if the patient has hypothalamic involvement and is at risk for the development of diabetes insipidus. The monitoring of serum electrolyte levels is important, especially in patients receiving osmotic diuretics, those with syndrome of inappropriate antidiuretic hormone (SIADH) secretion, and those with posttraumatic diabetes insipidus. Endocrine function is evaluated by monitoring serum electrolytes, blood glucose values, and intake and output. Urine is tested regularly for acetone

The physician has ordered a somatosensory evoked responses (SERs) test for a patient for whom the nurse is caring. The nurse is justified in suspecting that this patient may have a history of what type of neurologic disorder?

Demyelinating disease

A patient diagnosed with myasthenia gravis has been hospitalized to receive plasmapheresis for a myasthenic exacerbation. The nurse knows that the course of treatment for plasmapheresis in a patient with myasthenia gravis is what?

Determined by the patients response

The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurses most appropriate action?

Prepare for interventions to increase the patients BP

A young man with a diagnosis of hemophilia A has been brought to emergency department after suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the patients bleeding and established that his vital signs are stable. What should be the nurses next action?

Prepare for the administration of factor VIII.

The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply.

Vomiting Seizures Sudden, severe headache

autonomic dysreflexia what you need to do for that as a nurse, specific order done for best outcome for patient, know that specific order

autonomic dysreflexia (complication of pt that have spinal cord injury) - causes increase in BP which can cause ICP The following measures are carried out: •The patient is placed immediately in a sitting position to lower the blood pressure -Rapid assessment is performed to identify and alleviate the cause. •The bladder is emptied immediately via a urinary catheter. If an indwelling catheter is not patent, it is irrigated or replaced with another catheter. •The rectum is examined for a fecal mass. If present, a topical anesthetic agent is inserted 10 to 15 minutes before the mass is removed, because visceral distention or contraction can cause autonomic dysreflexia. •The skin is examined for any areas of pressure, irritation, or broken skin. •Any other stimulus that could be the triggering event, such as an object next to the skin or a draft of cold air, must be removed. -If these measures do not relieve the hypertension and excruciating headache, antihypertensive medications may be prescribed and given slowly by the IV route. •The medical record is labeled with a clearly visible indicator concerning the risk for autonomic dysreflexia. •The patient is instructed about prevention and management measures. -Any patient with a lesion above the T6 segment is informed that such an episode is possible and may occur even many years after the initial injury.