INPA Level 4 #1 UPDATED ACTUAL
Questions and CORRECT Answers
Diabetes complications - CORRECT ANSWER - - skin, urinary tract, and vaginal
infections possibly bc the elevated level of blood glucose supports bacterial growth
- changes in visual acuity b/c the hypertonicity of body fluid affects the cells in the retina and
lensluid affects the cells in the retina and lens
CVA pathophysiology - CORRECT ANSWER - prolonged interruption in the flow of
blood through one of the arteries supplying the brain
- ischemic: Thrombus or embolus obstructs an artery carrying blood to the brain.
- Hemorrhagic - Cerebral blood vessel ruptures and blood is released into brain tissue
Risk Factors of CVA (stroke) - CORRECT ANSWER - - inc. age
- male gender
- female gender post menopause
- heredity
- African descent
- Poorly controlled diabetes
- heart diseases, hypertension, arrhythmias
- obesity
- smoking & heavy alcohol use
- oral contraceptives
- history of TIA or CVA
S/S of CVA - CORRECT ANSWER - - depended on the area of brain effected
- Hemiplegia
Expressive and receptive aphasia
Confusion and emotional lability
,Hemianopia (ability to see only half of normal visual field)
nursing management CVA - CORRECT ANSWER - - Airway - o2
- Decrease ICP
- Nutrition
- Preserve function - promote self management
- Rehab - obtaining max functional and cognitive function
- Safety
- Education re: mobility aids, feeding aids, safe environment
- Prevention: modifying RF (smoking, nutrition, physical activity, BMI, BP, diabetes, lipids,
alcohol)
- Antiplatelets for prevention
- Thrombolytics
hemiplegia - CORRECT ANSWER - occurs opposite the area of the brain that is affected
because motor nerves cross over at the level of the neck
right sided hemiplegia - CORRECT ANSWER - Speech language deficits and slow
cautious behavior style, defects in right visual field
left sided hemiplegia - CORRECT ANSWER - - spatial - perceptual defects
- left sided neglect
- tends to deny/minimize info
- Rapid performance, short attention span
- Impulsive; safety problems
- Impaired judgement
increased ICP - CORRECT ANSWER - Increased pressure on the brain reducing
perfusion
, O2 levels fall & CO2 levels increase causing vasodilation leading to higher intracranial pressure
high icp s/s early - CORRECT ANSWER - headache, dizziness, N&V, memory loss,
confusion, lethargy, double vision, sluggish responses & respiratory changes
high icp s/s late - CORRECT ANSWER - deteriorating LOC, coma, fixed dilated pupils,
bradycardia, widening pulse pressure, abnormal posturing, absent responses.
nursing intervention for clients with actual or potential increased intracranial pressure -
CORRECT ANSWER - Neurological assessments & VS
Report unusual changes
Calm environment, treat pain, maintain comfort
Elevate HOB 15-30 degrees
Monitor I&O
Prevent flexed hips or excessive head movements
CVA complications - CORRECT ANSWER - Extension of hemorrhage or rebleed (Watch
for sudden LOC change)
Seizures
Hydrocephalus (buildup of fluid)
death
CVA diagnostic tests - CORRECT ANSWER - blood studies
pet scan
ct
MRI
eeg
Questions and CORRECT Answers
Diabetes complications - CORRECT ANSWER - - skin, urinary tract, and vaginal
infections possibly bc the elevated level of blood glucose supports bacterial growth
- changes in visual acuity b/c the hypertonicity of body fluid affects the cells in the retina and
lensluid affects the cells in the retina and lens
CVA pathophysiology - CORRECT ANSWER - prolonged interruption in the flow of
blood through one of the arteries supplying the brain
- ischemic: Thrombus or embolus obstructs an artery carrying blood to the brain.
- Hemorrhagic - Cerebral blood vessel ruptures and blood is released into brain tissue
Risk Factors of CVA (stroke) - CORRECT ANSWER - - inc. age
- male gender
- female gender post menopause
- heredity
- African descent
- Poorly controlled diabetes
- heart diseases, hypertension, arrhythmias
- obesity
- smoking & heavy alcohol use
- oral contraceptives
- history of TIA or CVA
S/S of CVA - CORRECT ANSWER - - depended on the area of brain effected
- Hemiplegia
Expressive and receptive aphasia
Confusion and emotional lability
,Hemianopia (ability to see only half of normal visual field)
nursing management CVA - CORRECT ANSWER - - Airway - o2
- Decrease ICP
- Nutrition
- Preserve function - promote self management
- Rehab - obtaining max functional and cognitive function
- Safety
- Education re: mobility aids, feeding aids, safe environment
- Prevention: modifying RF (smoking, nutrition, physical activity, BMI, BP, diabetes, lipids,
alcohol)
- Antiplatelets for prevention
- Thrombolytics
hemiplegia - CORRECT ANSWER - occurs opposite the area of the brain that is affected
because motor nerves cross over at the level of the neck
right sided hemiplegia - CORRECT ANSWER - Speech language deficits and slow
cautious behavior style, defects in right visual field
left sided hemiplegia - CORRECT ANSWER - - spatial - perceptual defects
- left sided neglect
- tends to deny/minimize info
- Rapid performance, short attention span
- Impulsive; safety problems
- Impaired judgement
increased ICP - CORRECT ANSWER - Increased pressure on the brain reducing
perfusion
, O2 levels fall & CO2 levels increase causing vasodilation leading to higher intracranial pressure
high icp s/s early - CORRECT ANSWER - headache, dizziness, N&V, memory loss,
confusion, lethargy, double vision, sluggish responses & respiratory changes
high icp s/s late - CORRECT ANSWER - deteriorating LOC, coma, fixed dilated pupils,
bradycardia, widening pulse pressure, abnormal posturing, absent responses.
nursing intervention for clients with actual or potential increased intracranial pressure -
CORRECT ANSWER - Neurological assessments & VS
Report unusual changes
Calm environment, treat pain, maintain comfort
Elevate HOB 15-30 degrees
Monitor I&O
Prevent flexed hips or excessive head movements
CVA complications - CORRECT ANSWER - Extension of hemorrhage or rebleed (Watch
for sudden LOC change)
Seizures
Hydrocephalus (buildup of fluid)
death
CVA diagnostic tests - CORRECT ANSWER - blood studies
pet scan
ct
MRI
eeg
