MDC 4 Exam1 Fully Answered- Graded A+ -Rasmussen University

Which Migraine medications cannot be used in a patient with cardiac diseases and why? - ANSWER Triptans and Ergotamine preparations- they will cause additional vasoconstriction of the head blood vessels What does abor ...

Which Migraine medications cannot be used in a patient with cardiac diseases and why? - ANSWER Triptans and Ergotamine preparations- they will cause additional vasoconstriction of the head blood vessels What does abortive therapy do for migraines? - ANSWER alleviate pain after the headache starts What does preventative therapy do for migraines? - ANSWER prevent a headache is it occurs more than twice a week or is severe. A patient is taking beta blocker and calcium channel blockers to prevent a migraine. What education should the nurse give to the patient regarding these medications? - ANSWER Do not stop the medications What are some trigger foods for migraines? - ANSWER aged cheeses, smoked meats, fermented deli meats, pickles, beer, wine, nuts (think tyramine) A patient is trying to see what things trigger their migraines. What education can the nurse provide? - ANSWER Keep a food diary and determine what foods may make the migraine occur. A patient tells the nurse that they see flashing lights before their headache starts. What is this called? - ANSWER Aura A aura may happen with _______ and ________. - ANSWER Migraines, Seizures S/S of Migraines - ANSWER Photophobia, N,V,head pain, phonophobia A patient tells their spouse who is a nurse they are having a migraine. What would the nurse tell them to do? - ANSWER Go into a cool dark room and rest while sitting up. A nurse is setting up a room for a patient coming in for a seizure. What things should be included in the room? - ANSWER Working suction and o2, padded bed side rails, placement of an IV when patient arrives. What should you never place in a patients mouth when they are having a seizure? - ANSWER Tongue blade What is the term for a seizure lasting more than 5 minutes or having multiples in a 30 min period? - ANSWER Status Epilepticus What can you give to stop a seizure? - ANSWER IV benzo A patient states to the nurse before leaving the doctors office his provider will place him on phenytoin. What education should the nurse give? - ANSWER Do not stop the medication- if so a seizure may occur. A patient with a seizure disorder suddenly freezes up and drops without twitching. What type of seizure is this called? - ANSWER Tonic A patient with a seizure disorder suddenly freezes up for a few seconds and starts to vigorously twitch. What type of seizure is the patient having? - ANSWER Tonic Clonic A person starts to have brief twitches of their left arm while in line to check out at the store. What type of seizure is this? - ANSWER Myoclonic A patient suddenly looses muscle tone and drops to the floor. What type of seizure is this? - ANSWER Atonic A nurse starts to see the patient in a room starting to have a seizure. What is her next move? - ANSWER Place patient on left side, lower bed, support head, no restraining them, timing the episode and calling for help. After a seizure is done, what actions should the nurse take? - ANSWER Assess vitals, reorient patient, clean them up if they peed or pooped, call provider. A teen with a seizure disorder is cleared by the provider to take his drivers license test. What must her report to the DMV? - ANSWER That he has a seizure disorder A female patient was recently diagnosed with a seizure disorder and is taking a oral contraceptive. What education must the nurse give? - ANSWER She should switch off the pill as seizure prevention medications can cause the pill to not work. S/S of Parkinsons include: - ANSWER bradykinesia, muscle rigidity, mask like face, postal instability, resting tremors, cogwheel rigidity, lead pipe rigidity, shuffling gait What are some concerns regarding Parkinsons disease? - ANSWER Safety- fall precautions needed Aspiration- may need assistance or observation while eating Who is at risk for developing MS? - ANSWER Females ages 20-40 S/S of MS: - ANSWER based on area affected, fatigue, double vision, HA, trigeminal neuralgia, dysarthria, ataxia, incontinence, nystagmus. MS treatment - ANSWER steroids and the S/S What is a hallmark manifestation of guillan barre? - ANSWER Ascending paralysis What is a concern we can have with guillan barre? - ANSWER Will eventually reach its way to diaphragm and cause respiratory compromise and need for mechanical ventilation When can one get Gillian barre? - ANSWER After a virus or vaccine What is trigeminal neuralgia? - ANSWER Pain of the CN 5, causes pain in the face. What is one medication we can give to a patient experiencing spasms of the face from trigeminal neuralgia? - ANSWER Baclofen What are the highest priorities during the post-op period? - ANSWER Patent airway and oxygen saturation At what level of the body will a patient have autonomic dysreflexia? - ANSWER Above a T6 fracture A patient with a T1 fracture starts to have a headache and flushing of the skin. his most recent vitals are BP 170/90, HR is 50. What are interventions to assist with these manifestations? - ANSWER Sit them up and look for a cause such as a full bladder and solve it What are some preoperative priorities? - ANSWER Confirm consent is signed, verify any allergies, educate patient on what to expect during and after the procedure, ensure patient has been NPO for 6-8 hrs, baseline vitals, confirm the most recent labs, medications, pregnancy test. What can UAPs not do? - ANSWER Assess, evaluate, or teach. No unstable patients, no meds, no invasive procedures. A patient who had a stroke has his meal on the floor. No modified barium swallow has been done yet. The UAP asks to go feed the patient. Should the nurse intervene? - ANSWER Yes- the patient could aspiration without having the proper diet and feeding precautions established Parts of the Glasgow Coma Scale are: - ANSWER Eye opening response, motor response, verbal response. If a patient has a GCS score of 8, what are they most likely in? - ANSWER Coma If a patient has a GCS score of 3, what is happening? - ANSWER They dead Decorticate posturing - ANSWER characterized by upper extremities flexed at the elbows and held closely to the body and lower extremities that are externally rotated and extended. occurs when the brainstem is not inhibited by the motor function of the cerebral cortex. Decerebrate posturing - ANSWER posturing in which the neck is extended with jaw clenched; arms are pronated, extended, and close to the sides; legs are extended straight out; more ominous sign of brain stem damage. Most Severe. What are priorities when patient is in the OR? - ANSWER Safety and Infection Control What is evisceration? - ANSWER protrusion of visceral organs through a wound opening What is dehiscence? - ANSWER A separation of the wound incision A patient tells the nurse that when he went to cough her felt a popping sensation. Part of his intestines is out. What does the nurse do next? - ANSWER Call for help, place a sterile moistened gauze over the area, patient will go to OR. How do we know a JP drain is working? - ANSWER The bulb is squeezed and collapsed for suction Who should the nurse place a consult in for a patient who had a stroke and needs a swallow eval? - ANSWER Speech Therapist A nurse notices a patient with a head injury has clear fluid draining from his ear. What is the nurses next action? - ANSWER Assess it for presence of CSF with halo sign and glucose concentration What interventions should the nurse do for a patient with increased ICP? - ANSWER Provide a low stimuli, quiet room with patient sitting up with head in neutral position. A nurse sees that a patient with an ICP of 24 is going for an lumbar puncture. What is the nurses next action? - ANSWER Call the provider to have the procedure cancelled as increased ICP is contraindicated for a lumbar puncture. What medication can be given to reduce increased ICP? - ANSWER Mannitol through a filter needle What are early s/s of increased ICP - ANSWER LOC change, vision changes What are late s/s of increased ICP? - ANSWER vomiting, blown pupils, Cushing triad What are parts of Cushing Triad? - ANSWER bradycardia, widen pulse pressure, Cheyne stoke respiration Aphasia - ANSWER inability to speak or understand language