NUR390 UPDATED EVALUATION EXAM
QUESTIONS AND ANSWERS SURE A+
✔✔Cushing's triad - ✔✔three classic signs—bradycardia, hypertension, and
bradypnea—seen with pressure on the medulla as a result of brain stem herniation
✔✔Neuro floor prioritization - ✔✔- Airway, breathing - aspiration risk, decreased GCS <
8, can't maintain airway
- Acute change in status patient - new FAST, sudden LOC change, status eplepticus
- Increased ICP - look for cushing's triad, pupil changes
- Safety alert patient - severe headache, still neck, confusion, rash --> meningitis
- new neuro deficit
- unequal pupils
** think acute vs stable
✔✔SLE lab findings to report - ✔✔- Kidney labs: creatinine, BUN, proteinuria, decrease
in urine output, GFR, dark colored urine
- CBCs for WBCs for leukopenia b/c SLE often attacks own blood cells
- Flare inflammatory markers: C-reactive protein, ESR
- Increased ANA (positive)
, - Increased Anti-dsDNA
- Decreased complement gain levels C3, C4
- proteinuria
- worsening renal function
- severe inflammation
✔✔Lupus nephritis - ✔✔serious complication of SLE
increased creatine
increased BUN
abnormal urinalysis (protein, RBC, cellular cast)
need early recognition to preserve renal
✔✔Lupus nephritis nursing intervention - ✔✔prepare client for renal biopsy
initiate fluid restrictions
✔✔myasthenia gravis - ✔✔a chronic autoimmune disease that affects the
neuromuscular Ach junction and produces serious weakness of voluntary muscles
✔✔myasthenia gravis signs & symptoms - ✔✔eyes: ptosis, diplopia
bulbar: dysphagia, nasal voice, snarly expression
limbs: proximal limb weakness - shoulders/hips
respiratory weakness: medical emergency
✔✔myasthenia crisis - ✔✔muscles that control breathing weaken to the point of
compromised ventilation
- respiratory failure
- warning signs: dyspnea, bulbar weakness (swallowing muscles) = high risk of choking
and saliva aspiration
- inability to clear secretions (can't cough)
- slurred speech
- precipitated by infection, surgery, med interaction, stress
✔✔myasthenia gravis test - ✔✔Tensilon test- edrophonium (Tensilon) is administered.
A positive test indicates a marked improvement in muscle strength that lasts 5 min (
have Atropine available to counter effects)
✔✔MS most important intervention - ✔✔- respiratory compromise, airway, breathing
difficulty (myasthenia crisis)
- aspiration due to dysphagia
- preventing injury related to falls
QUESTIONS AND ANSWERS SURE A+
✔✔Cushing's triad - ✔✔three classic signs—bradycardia, hypertension, and
bradypnea—seen with pressure on the medulla as a result of brain stem herniation
✔✔Neuro floor prioritization - ✔✔- Airway, breathing - aspiration risk, decreased GCS <
8, can't maintain airway
- Acute change in status patient - new FAST, sudden LOC change, status eplepticus
- Increased ICP - look for cushing's triad, pupil changes
- Safety alert patient - severe headache, still neck, confusion, rash --> meningitis
- new neuro deficit
- unequal pupils
** think acute vs stable
✔✔SLE lab findings to report - ✔✔- Kidney labs: creatinine, BUN, proteinuria, decrease
in urine output, GFR, dark colored urine
- CBCs for WBCs for leukopenia b/c SLE often attacks own blood cells
- Flare inflammatory markers: C-reactive protein, ESR
- Increased ANA (positive)
, - Increased Anti-dsDNA
- Decreased complement gain levels C3, C4
- proteinuria
- worsening renal function
- severe inflammation
✔✔Lupus nephritis - ✔✔serious complication of SLE
increased creatine
increased BUN
abnormal urinalysis (protein, RBC, cellular cast)
need early recognition to preserve renal
✔✔Lupus nephritis nursing intervention - ✔✔prepare client for renal biopsy
initiate fluid restrictions
✔✔myasthenia gravis - ✔✔a chronic autoimmune disease that affects the
neuromuscular Ach junction and produces serious weakness of voluntary muscles
✔✔myasthenia gravis signs & symptoms - ✔✔eyes: ptosis, diplopia
bulbar: dysphagia, nasal voice, snarly expression
limbs: proximal limb weakness - shoulders/hips
respiratory weakness: medical emergency
✔✔myasthenia crisis - ✔✔muscles that control breathing weaken to the point of
compromised ventilation
- respiratory failure
- warning signs: dyspnea, bulbar weakness (swallowing muscles) = high risk of choking
and saliva aspiration
- inability to clear secretions (can't cough)
- slurred speech
- precipitated by infection, surgery, med interaction, stress
✔✔myasthenia gravis test - ✔✔Tensilon test- edrophonium (Tensilon) is administered.
A positive test indicates a marked improvement in muscle strength that lasts 5 min (
have Atropine available to counter effects)
✔✔MS most important intervention - ✔✔- respiratory compromise, airway, breathing
difficulty (myasthenia crisis)
- aspiration due to dysphagia
- preventing injury related to falls
