Medical Surgical nursing 2 exam 1 Questions with Correct Answers

hyperthermia and icp - ANSWERSfever must be treated vigorously because it increases cerebral edema and seizures; can use Tylenol or aspirin anticoagulants and platelet inhibitors - ANSWERSnot recommended in the emergency phase after an ischemic stroke, aspirin may be iniated 24-48 hours after ischemic stroke; used to prevent further clot formation Transient ischemic attack - ANSWERSepisode of neurologic dysfunction caused by a focal brain, spinal cord, or retinal ischemia, but without acute infarction of the brain; may resolve or may develop into a stroke, treat as medical emergency tonic-clonic seizures - ANSWERScharacterized by losing consciousness and falling to the ground if the patient is upright, followed by stiffening of the body for 10 to 20 seconds and subsequent jerking of the extremities for another 30-40 seconds; other symptoms may include cyanosis, excessive salivation, tounge or cheek biting, and incontinence may accompany the seizure tonic clonic seizure nursing intervention - ANSWERSensure patent airway, protect from injury, remove or loosen clothing, suction as needed behavior changes in AD patients - ANSWERSoccur with 90% of patients; -repetitiveness -delusions -hallucinations -agitation -aggression -altered sleeping pattern -wandering -resisting care nursing intervention' -have stairways well lit -handrails should be graspable -tack down carpet edges -remove throw rugs and extension cords -use nonskid mats in tub or shower -install handrails in the bath and by the commode increased icp manifestations - ANSWERS-change in loc -change in vital signs -ocular signs -decrease in motor function -headache -vomiting hallux valgus - ANSWERSdeformity of great toe consisting of lateral angulation of great toe toward second toe bony enlargement of medial side of first metatarsal heal, swelling of bursa, and formation of callus over bony enlargement; may need internal fixation pain management and assessment - ANSWERSalways use pain scale, morphine can be used for acute pain management of hyperthermia - ANSWERSantipyretics(Tylenol), cool baths, cooling blanket, ice packs, intravascular cooling devices sprain - ANSWERS-rice -cold -elastic compression bandage -injured part should be elevated above the heart level to help mobilize excess fluid from the area