Final Exam Review: NUR2755/ NUR 2755 (Latest 2023 / 2024): - Multidimensional Care/ MDC IV Rasmussen- Rated A- Rasmussen

Final Exam Review: NUR2755/ NUR 2755 (Latest 2023 / 2024): - Multidimensional Care/ MDC IV Rasmussen- Rated A- Rasmussen 1. The nurse should teach the nurse trainee about this about ICP - remain above 30*, do not cough or sneeze forcefully, take stool softener for constipation 2. CSF appearance - Clear, colorless, rings of glucose, often associated with basilar fx 3. Seizure safety - Remove tight clothing, remove pillows and raise padded side rails, position client on side with head positioned forward 4. homonymous hemianopsia - The loss of the right or left half of the field of vision in both eyes. Safety: have patient turn their head to scan the lost visual field 5. myasthenia gravis education - advise patient to take medication as ordered 6. parkinsons mobility - educate the patient to rock back and forth to start a movement when experiencing bradykinesia 7. Guillian-Barr Syndrome - evolves from infectious process of GI or Respiratory tract 8. Kernig's sign - a diagnostic sign for meningitis marked by the person's inability to extend the leg completely when the thigh is flexed upon the abdomen and the person is sitting or lying down 9. Brudzinski's sign - pain with resistance and involuntary flex of hip/knee when neck is flexed to chest when lying supine. Menigitis 10. Patient education for halo device - Wash skin daily, use a straw for drinking, advise that the device can alter balance 11. Wound infection signs - red hard skin, purulent drainage, warm tender skin 12. Clinical manifestation PACU nurse should be concerned with - Respiratory rate 12 or below - elevated BP - Increased pain that is not resolved with pain medication 13. What are protonix used for? - prophylactic treatment for stomach ulcers 14. Who can sign a consent for a confused client? - Spouse, POA 15. When would a hospital disaster plan be activated? - Factory Explosion 16. When should a patient carry an epi pen? - if they have had previous anaphylaxis to wasp or bees stings 17. Prioritize patient treatment: #1 21 year old dazedwith laceration to face. #2 infant with fever, petechia and nucheal rigidy #3 25 year old with broken ankle and pulse #4 50 year old woman with abdominal pain - 2,1,4,3 18. Priority treatment: for patient with left sided chest pain and following vital signs; BP 140/90, RR 16, P90, O2 88% - Oxygen 19. Priority Action by nurse: Patient arrives with heat stroke, patient vitals are : 104.4, 88/50, p112, O2 88% - Oxygen-Start Iv-Administer IV fluids-Insert rectal themometor 20. Patient arrives to ER with temperature of 104 after working on the roof, what is the diagnosis and how do you treat? - Heat stroke- Do not give fluids by mouth or medications- remember heat stroke is similar to thrombolytic stroke they may be disoriented and unable