NSG 4100 Exam 4 questions with
correct answers 100%$ correct
Positive Kernig sign Pt. lies flat and thigh flexed on abdomen - leg unable to
completely extend
Positive Brudzinski Sign When pt. neck is flexed →knees & hips flex up from straight
*More sensitive indicator than kernig
Nursing Interventions ICP ↓ Noise/Light
Cluster care
Limit visitors
Pain meds
Seizure precautions
Monitor LOC, Labs, Urine
output Drain CSF (shunt)
Priority Nursing Intervention Respiratory support:
Huntington's w/pneumonia Incentive Spirometer
TCDB (turn cough deep breathe)
Humidified O2
CPT
Myasthenia gravis treatment Pyridostigmine to improve muscle strength & ADL's
Myasthenia Gravis complications missed Myasthenic Crisis:
doses Respiratory failure; neuromuscular respiratory failure
may require intubation
Most common clinical manifestations Trigger point
Fibromyalgia pain Difficulty
sleeping
, Nursing Education to prevent injury MS Falls Prevention:
Walk with feet apart to widen base
Watch feet while walking
Gait training
Assistive devices (walker, cane, braces
Amyotrophic lateral sclerosis (ALS) Neuromuscular weakness resulting in respiratory failure
complication that may require intubation
Functional ability by Level of Cord Injury Completely dependent for dressing, eating, elimination
C1 - C3 possible C4 Electric wheelchair
Functional ability by Level of Cord Injury Maximal Assistance elimination
C4 - C5 Independent w/ assistance eating/dressing
Functional ability by Level of Cord Injury Bowel control
C6 Minimal assist in transfers & wheelchair
Functional ability by Level of Cord Injury Ambulatory w/assist
T11 +
Autonomic Dysreflexia Exaggerated autonomic response to stimulation;
Triggers:
wrinkle in sheets, full bladder pressure, etc.
Most common cause of Autonomic SCI spinal cord injury
Dysreflexia T6 and above
What is seen Guillian-Barre? Muscle weakness, diminished reflexes, demyelination of
CSF? nerves
Protein in CSF
Gullian-Barre nursing interventions Medical emergency due to rapid progression to respiratory
failure:
Maintain Respiratory & Improve: TCDB, IS, CPT
bulbar weakness impairs ability to swallow & clear
secretions - suctioning
Enhance Mobility: DVT, pressure
ulcers Nutrition: prevent ileus, IV
fluids Communication
Decrease fear & Anxiety
Order of Priority Intervention in Burn 1. Obtain VS & hemodynamic status
Patient 2.Calculate TBSA affected
3.Calculate Parkland Formula
4. Dress wound w/sterile gauze
correct answers 100%$ correct
Positive Kernig sign Pt. lies flat and thigh flexed on abdomen - leg unable to
completely extend
Positive Brudzinski Sign When pt. neck is flexed →knees & hips flex up from straight
*More sensitive indicator than kernig
Nursing Interventions ICP ↓ Noise/Light
Cluster care
Limit visitors
Pain meds
Seizure precautions
Monitor LOC, Labs, Urine
output Drain CSF (shunt)
Priority Nursing Intervention Respiratory support:
Huntington's w/pneumonia Incentive Spirometer
TCDB (turn cough deep breathe)
Humidified O2
CPT
Myasthenia gravis treatment Pyridostigmine to improve muscle strength & ADL's
Myasthenia Gravis complications missed Myasthenic Crisis:
doses Respiratory failure; neuromuscular respiratory failure
may require intubation
Most common clinical manifestations Trigger point
Fibromyalgia pain Difficulty
sleeping
, Nursing Education to prevent injury MS Falls Prevention:
Walk with feet apart to widen base
Watch feet while walking
Gait training
Assistive devices (walker, cane, braces
Amyotrophic lateral sclerosis (ALS) Neuromuscular weakness resulting in respiratory failure
complication that may require intubation
Functional ability by Level of Cord Injury Completely dependent for dressing, eating, elimination
C1 - C3 possible C4 Electric wheelchair
Functional ability by Level of Cord Injury Maximal Assistance elimination
C4 - C5 Independent w/ assistance eating/dressing
Functional ability by Level of Cord Injury Bowel control
C6 Minimal assist in transfers & wheelchair
Functional ability by Level of Cord Injury Ambulatory w/assist
T11 +
Autonomic Dysreflexia Exaggerated autonomic response to stimulation;
Triggers:
wrinkle in sheets, full bladder pressure, etc.
Most common cause of Autonomic SCI spinal cord injury
Dysreflexia T6 and above
What is seen Guillian-Barre? Muscle weakness, diminished reflexes, demyelination of
CSF? nerves
Protein in CSF
Gullian-Barre nursing interventions Medical emergency due to rapid progression to respiratory
failure:
Maintain Respiratory & Improve: TCDB, IS, CPT
bulbar weakness impairs ability to swallow & clear
secretions - suctioning
Enhance Mobility: DVT, pressure
ulcers Nutrition: prevent ileus, IV
fluids Communication
Decrease fear & Anxiety
Order of Priority Intervention in Burn 1. Obtain VS & hemodynamic status
Patient 2.Calculate TBSA affected
3.Calculate Parkland Formula
4. Dress wound w/sterile gauze
