NSG 4100 Exam 4 Study Study With Verified
Answers
High Blood pressure is priority over a high heart rate!!!
Unit 8 Complex Neurological Problems
• Head trauma – prioritize care, what would require immediate intervention?
CSF FROM EAR= EMERGENCY
Bruising over mastoid bone
Temp OVER 100. 4
-Changes in pupils - not PERLA
-Sluggish
-Uneven
-Greater or less than 2-4
s/s of posturing:
-Decerabit
-Decorticate
*** a patient that is peeing a lot in a short amount of time, is a concern (DILUTE URINE)
-Nursing care- Neuro assessment (GCS SCALE) any decrease in number = Increased ICP!
• Traumatic brain injury (TBI) – prioritize care, what would require immediate
intervention?
What would you do if someone came in non-responsive and all you could do is assess
them?
-Check pulse
-Utilize Glasgow coma scale (GCS)
-Give prophylactic or propofol to prevent seizures
• Increased intracranial pressure (ICP)
-DO NOT let the systolic BP get above 130!!! and no big j umps, they ’re indicative of a
brain bleed or increased ICP. (Most likely needs to go back to the OR)
-KEEP HOB at 30-40 DEGREES
-Sudden restlessness without reason
• Increased ICP nursing intervention
o Seizure precautions, BP/ICP monitoring
o HOB 30-40 degrees
o Medication - mannitol or hy pertonic saline
o Reducing metabolic demands
Downloaded by Amber Kelly ()
, • Craniotomy - plan of care post op, assessment post op
-(Headaches and periorbital edema are common with these procedures)
- If the drain has 50-100 ml per shift that is too much, call the MD.
-Can lead to DI and SIADH, keep an eye on urine output. Everyone automatically gets a
foley.
-Post op goal of these procedures is to reduce the edema, control their pain, prevent
seizures, monitor BP
-Leaking can happen in places you wouldn’t suspect such as nose, ear, mouth (salty
taste), postnasal drip.
-Patient will be on anticonvulsant to reduce post op seizure risk
-MONITOR FOR INFECTION, CSF, AND SEIZURES
• Meningitis – what patients are more susceptible to opportunistic variations of
meningitis?
-College or military
-Immunocompromised
-Prevention (Meningococcal immunization at 11 years old with a booster at 16)
-Droplet precautions
• Care of the client with encephalitis.
Nursing interventions:
o Comfort measures - cluster care, dim lights, low noise, limit visitors - candidate
for farther away from nurses station
o Seizure precautions
o Neuro checks Q1 HOUR
-Give acyclovir for 3 weeks (HSV type 1)
Huntington’s disease – plan of care when other conditions exist.
Pyridostigmine for myasthenia graves – expected outcomes
o Pyridostigmine (acetylcholinesterase inhibitor) - increase muscle strength
• Myasthenia graves treatment and client education
-Medical management
-Teach eyelid taping
-Avoid sedatives
-Stress reduction techniques
-Sit upright for meals, soft foods
-Large meal in the morning, small meals in evening
o Assessment of swallowing, teaching swallowing techniques
-Risk for aspiration
o Myasthenic crisis - airway support, ABGs, avoiding sedatives (create further
concern of airway), chest physiotherapy
Downloaded by Amber Kelly ()
Answers
High Blood pressure is priority over a high heart rate!!!
Unit 8 Complex Neurological Problems
• Head trauma – prioritize care, what would require immediate intervention?
CSF FROM EAR= EMERGENCY
Bruising over mastoid bone
Temp OVER 100. 4
-Changes in pupils - not PERLA
-Sluggish
-Uneven
-Greater or less than 2-4
s/s of posturing:
-Decerabit
-Decorticate
*** a patient that is peeing a lot in a short amount of time, is a concern (DILUTE URINE)
-Nursing care- Neuro assessment (GCS SCALE) any decrease in number = Increased ICP!
• Traumatic brain injury (TBI) – prioritize care, what would require immediate
intervention?
What would you do if someone came in non-responsive and all you could do is assess
them?
-Check pulse
-Utilize Glasgow coma scale (GCS)
-Give prophylactic or propofol to prevent seizures
• Increased intracranial pressure (ICP)
-DO NOT let the systolic BP get above 130!!! and no big j umps, they ’re indicative of a
brain bleed or increased ICP. (Most likely needs to go back to the OR)
-KEEP HOB at 30-40 DEGREES
-Sudden restlessness without reason
• Increased ICP nursing intervention
o Seizure precautions, BP/ICP monitoring
o HOB 30-40 degrees
o Medication - mannitol or hy pertonic saline
o Reducing metabolic demands
Downloaded by Amber Kelly ()
, • Craniotomy - plan of care post op, assessment post op
-(Headaches and periorbital edema are common with these procedures)
- If the drain has 50-100 ml per shift that is too much, call the MD.
-Can lead to DI and SIADH, keep an eye on urine output. Everyone automatically gets a
foley.
-Post op goal of these procedures is to reduce the edema, control their pain, prevent
seizures, monitor BP
-Leaking can happen in places you wouldn’t suspect such as nose, ear, mouth (salty
taste), postnasal drip.
-Patient will be on anticonvulsant to reduce post op seizure risk
-MONITOR FOR INFECTION, CSF, AND SEIZURES
• Meningitis – what patients are more susceptible to opportunistic variations of
meningitis?
-College or military
-Immunocompromised
-Prevention (Meningococcal immunization at 11 years old with a booster at 16)
-Droplet precautions
• Care of the client with encephalitis.
Nursing interventions:
o Comfort measures - cluster care, dim lights, low noise, limit visitors - candidate
for farther away from nurses station
o Seizure precautions
o Neuro checks Q1 HOUR
-Give acyclovir for 3 weeks (HSV type 1)
Huntington’s disease – plan of care when other conditions exist.
Pyridostigmine for myasthenia graves – expected outcomes
o Pyridostigmine (acetylcholinesterase inhibitor) - increase muscle strength
• Myasthenia graves treatment and client education
-Medical management
-Teach eyelid taping
-Avoid sedatives
-Stress reduction techniques
-Sit upright for meals, soft foods
-Large meal in the morning, small meals in evening
o Assessment of swallowing, teaching swallowing techniques
-Risk for aspiration
o Myasthenic crisis - airway support, ABGs, avoiding sedatives (create further
concern of airway), chest physiotherapy
Downloaded by Amber Kelly ()
