Study guide for PBDS| QUESTIONS WITH COMPLETE SOLUTIONS

CVA nursing diagnosis Correct Answer: inadequate tissue perfusion CVA Signs and Symptoms & RF Correct Answer: muscle weakness, facial drooping, slurred speech, vision changes, HA, arm numbness RF: HTN, previous TIA, oral contraceptive, alcohol, smoking, diabetes, older age, heart condition Nursing interventions for CVA Correct Answer: Stat vitals and neuro assessment, call rapid response, monitor BP, administer BP meds, anticipate coagulation therapy, give o2 if needed, place in semi flowers assess: memory, mobility, language/speech, ability to swallow, pupils, neuro checks every hour CVA orders to anticipate and interdisciplinary care Correct Answer: CBC, electrolytes, INR/PT/PTT, TPA, CT, MRI, Doppler flow rehab: occupational therapy, PT, social work acute renal failure (ARF) nursing diagnosis Correct Answer: risk for decreased CO ARF signs and symptoms Correct Answer: hematuria, hyperkalemia/magnesemia, increased serum uric acid, low GFR, high SG, decreased UO, fluid retention, SOB, confusion, back pain, edema Causes: illness, trauma, medications, HF ARF Nursing interventions Correct Answer: hx- current meds, infection, assess pain maintain aseptic technique, monitor cardiac function and assess for HTN, assess electrolytes, low protein diet with carbs, low potassium ARF Orders Correct Answer: cardiac monitor, urinalysis, urine electrolytes/osmolality, creatinine/BUN, magnesium/potassium, renal profile, angiogram, cystoscopy, bleeding time, renal scan, CT scan,kidney ultrasound, daily weight, IV fluids consult with infectious dx and nephrologist Anticipate diuretics ICP or intracranial bleed signs and symptoms Correct Answer: restless, irritable, increased BP, confused, lethargic, postural changes, HA, N/V, seizures ICP nursing interventions Correct Answ