MDC 4 Exam 1 Questions and Answers

Patient interventions for Complications from spinal cord injuries - ANSWER Autonomic dysreflexia, paralysis Breathing issues FAST for Bells palsy - ANSWER F- Face/ does the persons face look uneven A- Arm weakness ...

Patient interventions for Complications from spinal cord injuries - ANSWER Autonomic dysreflexia, paralysis Breathing issues FAST for Bells palsy - ANSWER F- Face/ does the persons face look uneven A- Arm weakness S- Speech difficulty T- Time to call 911 What cervical level of injury requires ventilation - ANSWER C3 and higher What life threatening condition happens with paraplegia - ANSWER Autonomic dysreflexia Skin break down Infection Patient education for Complications from spinal cord injuries - ANSWER How do you prevent ICP? - ANSWER Elevate HOB, Keep head midline, 02 above 94% What causes ICP? - ANSWER Head trauma Infection Increased CSF Hemorrhage Tumors Assessment findings for intracranial pressure - ANSWER Headache Shallow breathing Nausea confusion Increased blood pressure Anything blow ____ you need to ______ - ANSWER 8 Intubate for ICP Patient education after head injuries - ANSWER Reduce ICP Post-op infections Straight up and down No alcohol (bleeding) What medications are used to prevent migraines - ANSWER Preventive -Beta Blocker -Calcium channel blockers What medications are used to aborb migraines? - ANSWER Tylenol Ibuprofen Triptans for severe HA Ergotamine Midrin How do Preventive drugs for migraines work - ANSWER These aid in preventing vascular changes and are used to manage, not treat acute episodes How do abortive drugs for migraines work - ANSWER Help stop a migraine from coming on Dietary education for prevention of migraines - ANSWER AVOID things such as: ETOH Tyramine high foods Caffeine Chocolate Foods with yeast MSG Nitrates Artificial sweetener Smoked foods What is the action of migraine medication - ANSWER Vasoconstriction What causes Migraine Pain - ANSWER Vasodilation Patient education for prevention of migraines - ANSWER Avoid triggers Do yoga Relaxation Meditation Decrease stimulation during acute episode Ictal phase Nursing care - ANSWER Observe and document time of seizure and length Do not restrain patient but protect them from injury Maintain airway with O2 and suction Turn to prevent aspiration Postictal phase Nursing care - ANSWER Monitor for LOC, Orientation, & Motor ability to return to baseline More than 10 minutes can be fatal status epilepticus - ANSWER After 5 min if continuous episodes patient is treated as _______ __________, 30 min or more of seizure activity will result in neurological consequences signs of tonic-clonic seizure - ANSWER stiffening & jerking patient education of seizures - ANSWER Take drugs on time Take AED as prescribed (good Oral hygiene and Oral contraceptive barrier) Nursing interventions for seizures - ANSWER Nothing in mouth Turn on side Maintain airway Loosen restrictive clothing, Record time of seizure Treatment for Myasthenia Gravis - ANSWER Anticholinesterases (ChE first line) Immunosuppressants Plasma parisis What condition has IGG therapy - ANSWER Myasthenia Gravis Patient intervention for myasthenia gravis - ANSWER Avoid extreme heat and cold Avoid infection. Monitor for cholinergic crisis and myasthenic crisis Assessment findings for myasthenia gravis - ANSWER New onset weakness Limitations on ADL Drooping eyes (Ptosis) Double vision (Diplopia) Dysphagia (difficultly chewing or swallowing) Hall mark finding for Myasthenia Gravis - ANSWER Progressive muscle weakness Weakness starts proximal to distal Patient gets weak from the core first. Shoulders get weak before hands Inverventions for multiple sclerosis - ANSWER Increase Exercise Increase Vitamin D Memory boosting programs Decrease salt use Stop smoking What does the Glasgow Coma Scale measure? - ANSWER Measures LOC after brain injury Eyes (4-1) Movement (6-1) Voice (5-1) How to care for a patient with homonymous hemianopia after a stroke? - ANSWER Turn head side to side to expand visual field Scanning technique is useful when eating or ambulating How to Care for a patient with Left side stroke and right sided deficit - ANSWER Reorient as needed Establish a structured routine Encourage patient todo ADL as independently as possible Give patient simple easy to follow instructions What do Left side stroke patients with right side deficits experience? - ANSWER Aphasia (Inability to speak) Alexia (Difficulty reading) Agraphia (Difficulty writing) Acalculia (Difficulty with math) What do Right side stroke patients with Left side deficits experience? - ANSWER Impaired sense of Humor Disorientation of time, place and person Loss of depth perception Impulsiveness Loss of ability t hear tonal variations Left side hemiplegia or hemiparesis Patient education for parkinsons - ANSWER Report dizziness Delirium Maintain quality of life Help alleviate or manage symptoms Take medication at the same time How to manage a patient with proprioception (position sense)? - ANSWER Teach the patient to touch and use both sides of the body. When dressing, remind the patient to dress the affected side first. Assessment findings for parkinsons - ANSWER Tremors Muscle rigidity Bradykinesia Postural instability Medication for parkinsons - ANSWER Carbidopa/ Levodopa Give at set time do not change assessing gbs - ANSWER Halmark finding: Ascending paralysis which can cause acute respiratory failure Patient interventions for gbs - ANSWER Monitor vitals and ECG Help feed patient if needed Maintain hydration passive ROM Q2 turns What is a patient with GBS at risk for - ANSWER Respiratory compromise Swallowing disorders Assessment finding for bells palsy - ANSWER Facal drooping unilateral Loss of cornea reflex on one side Loss of taste on one side Excess tearing on one side Excess drooling Cant sip or chew on one side Patient education for bells palsy - ANSWER Tape eye closed or wear a patch QHS, protective glasses while awake Manually close eyelid often High-calorie snacks, soft diet Warm, moist compresses and massage to the affected area Don't chew on face What is Generalized - ANSWER Reversible LOC, inhibits neuronal impulses when is generalized anesthesia appropriate? - ANSWER Major surgeries such as Open heart Brain surgery When is local anesthesia appropriate? - ANSWER Used in patients that just need a quick procedure while still conscious such as Skin Biopsy breast Biopsy Stitching a deep cut Use of regional anesthesia - ANSWER Numbs a much larger area but still keeps the patient conscious such as Epidurals what is Local Anesthesia - ANSWER Delivered topically and by local infiltration Moderate sedation Twilight sleep Conscious sedation Where is Regional anesthesia injected? - ANSWER Injected around major nerves to block sensationn and pain to a specific area of the body.