Fundamentals Nursing 1871 Test 2 CSCC Questions With
Complete Solutions
Ch 44: Pain management, Ch 46: Urinary Elimination, Ch 47:
Bowel Elimination, Ch 13: Intracranial Regulation, Ch 33:
Cognition, Ch 39: Immobility, Ch 31: Medication
Administration (Non-parenteral), Ch 21: Non-parenteral
Medication Administration, Ch 38: Clinical Judgement, Ch 57:
Health Care Law, Ch 23: Legal Implications in Nursing
Practice, Ch 26: Informatics and Documentation
Late Warning Sign of Intracranial Pressure (ICP)
Changes in cranial nerves in 2, 3, 4, and 6
- Edema and herniation are impacting the function of the pupils
and eye movements
Cerebral Edema
Swelling of the brain
- It has negative effects in perfusion and oxygenation
- It is a symptom not a disease
- Treat underlying condition
Causes of Cerebral Edema
- Lesions
- Trauma or surgery
- Cerebral infection (Encephalitis or meningitis)
- Vascular insults (Strokes)
- Encephalopathies (Arsenic poisoning
Stroke
,Inadequate oxygenation and perfusion to the brain or loss of
blood flow
- BE FAST
- Ischemic and hemorrhagic
Ischemic Stroke
Inadequate blood flow to the brain
- Thrombus(blood clot)/embolism
- More common
- Atrial fibrillation, hyperlipidemia
Atrial Fibriliation
Irregular and often rapid heart rate
Hyperlipidemia
High cholesterol
Hemorrhagic Stroke
Ruptured vessels in brain
- Hypertension
- Aneurysms
- No blood thinning medication
- A person with this type of stroke would complain of having the
worst headache
Aneurysms
Abnormal swelling of a blood vessel
Hypertension
High blood pressure
,Modifiable Risk Factors for Stroke
- Smoking (Leading cause for ischemic stroke)
- Hypertension (Leading cause for hemorrhagic stroke)
- Obesity
- Diabetes
- Heart disease
- Birth control (Possible formation of blood clots)
Nonmodifiable Risk Factors for Stroke
- Race (African Americans are 4 times more likely to have a
hemorrhagic stroke)
- Gender
- Family history
Spot a Stroke Mnemonic (BEFAST+CL)
- B: balance
- E: eyes
- F: face
- A: arms
- S: speech
- T: time
- C: it is important to check blood sugar
- L: last time patient acted normal
What is a person with Bell's Palsy unable to do?
Raise their eyebrows in their affected side
How long can the brain last without oxygen before the cells start
to die?
, 5 mins
Preventative Care for Stroke
- Reducing salt intake
- Diet low in saturated fat
- Blood pressure control
- Encouraging activity (30 mins a day)
Acute Care for Stroke
- Assess ABC and LOC
- Obtain last known well
- Obtain CT scan (Does not immediately show ischemia, but
shows hemorrhagic stroke..the results determine course of
treatment)
Interprofessional Care for Ischemic Stroke
- Start fibrinolytic therapy
- Blood pressure SBP<180
- Mechanism thrombecomy
Interprofessional Care for Hemorrhagic Stroke
- Blood pressure SBP<160
- External ventricular device (If presence of blood in ventricles)
Interprofessional Care for Stroke
- Neuro checks every hour for 24 hrs
- Neuro status can worsen over 72 hours
- Speech therapy consult (Cognitive and swallow evaluations)
BP Control for Ischemic Stroke
Complete Solutions
Ch 44: Pain management, Ch 46: Urinary Elimination, Ch 47:
Bowel Elimination, Ch 13: Intracranial Regulation, Ch 33:
Cognition, Ch 39: Immobility, Ch 31: Medication
Administration (Non-parenteral), Ch 21: Non-parenteral
Medication Administration, Ch 38: Clinical Judgement, Ch 57:
Health Care Law, Ch 23: Legal Implications in Nursing
Practice, Ch 26: Informatics and Documentation
Late Warning Sign of Intracranial Pressure (ICP)
Changes in cranial nerves in 2, 3, 4, and 6
- Edema and herniation are impacting the function of the pupils
and eye movements
Cerebral Edema
Swelling of the brain
- It has negative effects in perfusion and oxygenation
- It is a symptom not a disease
- Treat underlying condition
Causes of Cerebral Edema
- Lesions
- Trauma or surgery
- Cerebral infection (Encephalitis or meningitis)
- Vascular insults (Strokes)
- Encephalopathies (Arsenic poisoning
Stroke
,Inadequate oxygenation and perfusion to the brain or loss of
blood flow
- BE FAST
- Ischemic and hemorrhagic
Ischemic Stroke
Inadequate blood flow to the brain
- Thrombus(blood clot)/embolism
- More common
- Atrial fibrillation, hyperlipidemia
Atrial Fibriliation
Irregular and often rapid heart rate
Hyperlipidemia
High cholesterol
Hemorrhagic Stroke
Ruptured vessels in brain
- Hypertension
- Aneurysms
- No blood thinning medication
- A person with this type of stroke would complain of having the
worst headache
Aneurysms
Abnormal swelling of a blood vessel
Hypertension
High blood pressure
,Modifiable Risk Factors for Stroke
- Smoking (Leading cause for ischemic stroke)
- Hypertension (Leading cause for hemorrhagic stroke)
- Obesity
- Diabetes
- Heart disease
- Birth control (Possible formation of blood clots)
Nonmodifiable Risk Factors for Stroke
- Race (African Americans are 4 times more likely to have a
hemorrhagic stroke)
- Gender
- Family history
Spot a Stroke Mnemonic (BEFAST+CL)
- B: balance
- E: eyes
- F: face
- A: arms
- S: speech
- T: time
- C: it is important to check blood sugar
- L: last time patient acted normal
What is a person with Bell's Palsy unable to do?
Raise their eyebrows in their affected side
How long can the brain last without oxygen before the cells start
to die?
, 5 mins
Preventative Care for Stroke
- Reducing salt intake
- Diet low in saturated fat
- Blood pressure control
- Encouraging activity (30 mins a day)
Acute Care for Stroke
- Assess ABC and LOC
- Obtain last known well
- Obtain CT scan (Does not immediately show ischemia, but
shows hemorrhagic stroke..the results determine course of
treatment)
Interprofessional Care for Ischemic Stroke
- Start fibrinolytic therapy
- Blood pressure SBP<180
- Mechanism thrombecomy
Interprofessional Care for Hemorrhagic Stroke
- Blood pressure SBP<160
- External ventricular device (If presence of blood in ventricles)
Interprofessional Care for Stroke
- Neuro checks every hour for 24 hrs
- Neuro status can worsen over 72 hours
- Speech therapy consult (Cognitive and swallow evaluations)
BP Control for Ischemic Stroke
