NUR2214 Exam 3 complete Latest Actual
set with Questions and verified Answers
Body systems involved in has exchange - ANSWER-neurologic
respiratory
cardiovascular
labs indicative of impaired gas exchange - ANSWER-ABG
CBC
Sputum Exam
Skin tests
Pathologic analysis
S/S of adequate ventilation - ANSWER-breathing is quiet and effortless
sat 95-100
skin, nail beds, lips are appropriate color
thorax is symmetric with equal thoracic expansion bilaterally
spinous processes are in alignment;scapulae are bilaterally symmetric
AP is less than transverse
trachea is midline
breath sounds are clear
NI for increased ICP - ANSWER-elevate HOB to 30 degrees
distribute care
only suction when needed
hyperventilation (decreases perfusion, only short-term intervention)
bowel management ( stool softeners, laxatives)
assessment of increased ICP - ANSWER-sustained or equal to 20
s/s:
headache
decreased LOC
N/V
CN 6 palsies (inability to turn the eye laterally outward)
papilledema
periorbital bruising
late sign: cushings triad: hypertension, bradycardia, irregular breathing
Fibrinolytic therapy indications: - ANSWER-after an acute ischemic stroke
4.5 hours after
unless:
older than 80
anticoagulation less than or equal to 1.7
NIHSS > 25
Hx of diabetes and stroke
how to give fibrinolytic therapy: - ANSWER-dosage based on weight
perform double check of glucose
programmable pump, initial dose is 0.9mg/kg (max dose of 90mg) ocer 60 mins with 10% of dose as a
bolus over 1 min.
admit to critical care
perform neuro assessment and VS every 10-15 mins during infusion and every 30 mins after for at least 6
hours, monitor hourly for 24 hours after- be consistent with BP device
, if BP is over 180/105, administer anti-hypertensive
do not place invasive tubes
discontinue if pt reports severe headache, hypertension, bleeding, N/V
obtain follow-up CT, before anticoag/platelet drugs
ataxia - ANSWER-lack of muscle control or coordination of voluntary movements, such as walking or
picking up objects
broca's area: - ANSWER-in the frontal lobe
expressive (broca's or motor) aphasia: motor/speech problem, can understand, cannot express-has
difficulty writing
ischemic stroke - ANSWER-caused by a blockage of a cerebral artery by either a thrombus or emboli
causes of a thrombotic ischemic stroke - ANSWER-arthersclerosis
hypertension
s/s of thrombotic ischemic stroke - ANSWER-protein in CSF
slow onset
pt is awake
TIA
slight headache
speech deficits
visual problems
confusion
improvements over weeks-months
causes of embolic stroke - ANSWER-cardiac disease
s/s of embolic stroke - ANSWER-sudden onset
pt is awake
paralysis
expressive aphasia
rapid improvements
hemorrhagic stroke causes - ANSWER-hyptertension
vessel disorders
s/s of hemorrhagic stroke - ANSWER-abrupt onset
deepening stupor or coma
focal deficits
bloody CSF
usually seizures
permanent neurological deficits
homonymous meianopsia - ANSWER-blindness in the same side of both eyes
aneurysm - ANSWER-abnormal ballooning or blister along a normal artery
arteriovenous malformation (AVM) - ANSWER-tangled collection of malformed, thin-walled, dilated
vessels without capillary network
s/s of AVM: - ANSWER-severe headache
n/V
photophobia
cranial neuropathy
stiff neck
change in mental status
family hx
nursing care for AVM pt - ANSWER-PREVENT HYPERTENSION
monitor for s/s of hydrocephalus, vasospasm, hypertension
set with Questions and verified Answers
Body systems involved in has exchange - ANSWER-neurologic
respiratory
cardiovascular
labs indicative of impaired gas exchange - ANSWER-ABG
CBC
Sputum Exam
Skin tests
Pathologic analysis
S/S of adequate ventilation - ANSWER-breathing is quiet and effortless
sat 95-100
skin, nail beds, lips are appropriate color
thorax is symmetric with equal thoracic expansion bilaterally
spinous processes are in alignment;scapulae are bilaterally symmetric
AP is less than transverse
trachea is midline
breath sounds are clear
NI for increased ICP - ANSWER-elevate HOB to 30 degrees
distribute care
only suction when needed
hyperventilation (decreases perfusion, only short-term intervention)
bowel management ( stool softeners, laxatives)
assessment of increased ICP - ANSWER-sustained or equal to 20
s/s:
headache
decreased LOC
N/V
CN 6 palsies (inability to turn the eye laterally outward)
papilledema
periorbital bruising
late sign: cushings triad: hypertension, bradycardia, irregular breathing
Fibrinolytic therapy indications: - ANSWER-after an acute ischemic stroke
4.5 hours after
unless:
older than 80
anticoagulation less than or equal to 1.7
NIHSS > 25
Hx of diabetes and stroke
how to give fibrinolytic therapy: - ANSWER-dosage based on weight
perform double check of glucose
programmable pump, initial dose is 0.9mg/kg (max dose of 90mg) ocer 60 mins with 10% of dose as a
bolus over 1 min.
admit to critical care
perform neuro assessment and VS every 10-15 mins during infusion and every 30 mins after for at least 6
hours, monitor hourly for 24 hours after- be consistent with BP device
, if BP is over 180/105, administer anti-hypertensive
do not place invasive tubes
discontinue if pt reports severe headache, hypertension, bleeding, N/V
obtain follow-up CT, before anticoag/platelet drugs
ataxia - ANSWER-lack of muscle control or coordination of voluntary movements, such as walking or
picking up objects
broca's area: - ANSWER-in the frontal lobe
expressive (broca's or motor) aphasia: motor/speech problem, can understand, cannot express-has
difficulty writing
ischemic stroke - ANSWER-caused by a blockage of a cerebral artery by either a thrombus or emboli
causes of a thrombotic ischemic stroke - ANSWER-arthersclerosis
hypertension
s/s of thrombotic ischemic stroke - ANSWER-protein in CSF
slow onset
pt is awake
TIA
slight headache
speech deficits
visual problems
confusion
improvements over weeks-months
causes of embolic stroke - ANSWER-cardiac disease
s/s of embolic stroke - ANSWER-sudden onset
pt is awake
paralysis
expressive aphasia
rapid improvements
hemorrhagic stroke causes - ANSWER-hyptertension
vessel disorders
s/s of hemorrhagic stroke - ANSWER-abrupt onset
deepening stupor or coma
focal deficits
bloody CSF
usually seizures
permanent neurological deficits
homonymous meianopsia - ANSWER-blindness in the same side of both eyes
aneurysm - ANSWER-abnormal ballooning or blister along a normal artery
arteriovenous malformation (AVM) - ANSWER-tangled collection of malformed, thin-walled, dilated
vessels without capillary network
s/s of AVM: - ANSWER-severe headache
n/V
photophobia
cranial neuropathy
stiff neck
change in mental status
family hx
nursing care for AVM pt - ANSWER-PREVENT HYPERTENSION
monitor for s/s of hydrocephalus, vasospasm, hypertension
