NSG 4100 :Exams Test Appoved Questions
And Revised Answers For Tested Exams And
Mocks With A Grade(A+) Rationale
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 Huntington's w/pneumonia
Respiratory support:
Incentive Spirometer
TCDB (turn cough deep breathe)
Humidified O2
CPT
Myasthenia gravis treatment
Pyridostigmine to improve muscle strength & ADL's
Myasthenia Gravis complications missed doses
Myasthenic Crisis:
Respiratory failure; neuromuscular respiratory failure may require intubation
Most common clinical manifestations Fibromyalgia
Trigger point 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) complication
Neuromuscular weakness resulting in respiratory failure that may require intubation
Functional ability by Level of Cord Injury
C1 - C3 possible C4
Completely dependent for dressing, eating, elimination
Electric wheelchair
Functional ability by Level of Cord Injury
C4 - C5
Maximal Assistance elimination
Independent w/ assistance eating/dressing
Functional ability by Level of Cord Injury
C6
Bowel control
Minimal assist in transfers & wheelchair
Functional ability by Level of Cord Injury
T11 +
Ambulatory w/assist
Autonomic Dysreflexia
Exaggerated autonomic response to stimulation;
Triggers:
wrinkle in sheets, full bladder pressure, etc.
Most common cause of Autonomic Dysreflexia
SCI spinal cord injury
T6 and above
What is seen Guillian-Barre?
CSF?
Muscle weakness, diminished reflexes, demyelination of 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
And Revised Answers For Tested Exams And
Mocks With A Grade(A+) Rationale
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 Huntington's w/pneumonia
Respiratory support:
Incentive Spirometer
TCDB (turn cough deep breathe)
Humidified O2
CPT
Myasthenia gravis treatment
Pyridostigmine to improve muscle strength & ADL's
Myasthenia Gravis complications missed doses
Myasthenic Crisis:
Respiratory failure; neuromuscular respiratory failure may require intubation
Most common clinical manifestations Fibromyalgia
Trigger point 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) complication
Neuromuscular weakness resulting in respiratory failure that may require intubation
Functional ability by Level of Cord Injury
C1 - C3 possible C4
Completely dependent for dressing, eating, elimination
Electric wheelchair
Functional ability by Level of Cord Injury
C4 - C5
Maximal Assistance elimination
Independent w/ assistance eating/dressing
Functional ability by Level of Cord Injury
C6
Bowel control
Minimal assist in transfers & wheelchair
Functional ability by Level of Cord Injury
T11 +
Ambulatory w/assist
Autonomic Dysreflexia
Exaggerated autonomic response to stimulation;
Triggers:
wrinkle in sheets, full bladder pressure, etc.
Most common cause of Autonomic Dysreflexia
SCI spinal cord injury
T6 and above
What is seen Guillian-Barre?
CSF?
Muscle weakness, diminished reflexes, demyelination of 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
