Ati Med Surg 2 Exam 1 Exam Actual Exam Questions And Correct Detailed Answers

ATI med surg 2 exam 1 EXAM ACTUAL EXAM QUESTIONS AND CORRECT DETAILED ANSWERS Inc ICP Nursing interventions - ANSWER -HOB 15/30 degrees, dec. stimulation -airway: O2 + suctions (<10 secs at a time to prevent hypoxia) -give ant ipyretics, cool blankets, -no flexing of the hips -mouth care, eye care and DVT prevention -avoid certain positions like valsalva maneuver or flexing of the hip -monitor for infections if they had a ventriculostomy -frequent neuro checks -meds: antih ypertensives maintain MAP> 65, hyperosmotic fluids (watch out for dehydration: tenting of skin, dry mucous membrane, dec. bp, inc. hr ) -monitoring of ICP: GCS: 3 -8 (comatose pts) ventriculostomy: measures ICP AND collects CSF external -external ventr icular drain: only monitors ICP -subarachnoid bold: into the subarachnoid space and only monitors ICP INC ICP s/s - ANSWER -A MEDICAL EMERGENCY -s/s: headache, N/V, altered LOC/mental status, hemiplagia, cushings triad (wide bp, bradycardia, cheynes stokes respirations), papilledema, DOLL EYE: (when you turn left and your eyes stays on the right rather than turn w/ your head), decordicate/decerebrate posturing intracerebral hemorrhage - ANSWER -bleeding in the parenchyma (funcitonal tissues of our brain) s/s: THUNDERCLAP HEADACHE, NUCHAL RIGIDITY, SEIZURES -normally due to aneurysms , bleeding disorder, anticoagulation therapy complications, AVMs, nursing interventions: supportive care: maintain ICP, control IVF, antihypertensives, and electrolytes we give .watch out for rebleeding and PTvasospams (give clacium channel blocker), . SIADH + cerebral salt wasting can cause hyponatremia -watch out for fevers + seizures (aura, uncontrollable twitching, staring, fall, confusion) -surgical intervention: cr aniostomy, burr hole, shunt, aneurysm repair, stereotactic procedure Ischemic strokes - ANSWER -strokes due to clots -embolisms (clot from body), thrombosis (clot formed @ head/neck) -most common ones are lacunar strokes (which are formed at penetrating small arteries) that ususally result from standing for long periods of time, HTN, diabetes, hyperlipidemia. treatment: thrombolytic / catherization where we remove the clot ALS nursing management - ANSWER -RESPIRATION: they will probs have a tracheostomy (that's ma naged at home) they will probs have a paradoxymal lung movement making it look like a seesaw -assess QOL -assess dysphagia (assess swallowing and aspiration risk) Amytrophic Lateral Sclerosis (ALS) + manifestations - ANSWER -Think stephen hawking -degene rative disease of BOTH upper and lower motor neurons (but retains cognitive abilities) gradual onset of asymmetric and progressive limb weakness -s/s: . progressive muscle weakness that's asymmetrical =dysarythia, dysphagia, paralysis (think resp. paralysis) fatigue .but they retain their cognitive abilities ***they will probs die 3 -5 years after diagnosis but usually before due to infection anterior (ventral) cord syndrome - ANSWER -a incomplete cord injury -anterior cord is in charge of motor, pain and temperature sensation -ventral cord is in charge of sympathetic NS -s/s severe pain @ site of injury and maybe bladder incontinence -caused by HYPOTENSION = ISCHEMIA (cord compression, MI, embo lism, aortic aneurysm repair) basilar artery - ANSWER -this is the artery by the back of the neck and it supplies our cerebellum so when it's damaged we can see issues w/ our breathing and movements basilar skull fractures - ANSWER -this occurs by the basilar artery which is also connected to the paranasal