Nur 508 Final Exam Questions With
Complete Solutions!!
Which assessment findings relate to a thoracic spinal cord injury? - ANSWER- -
paraplegia
-paralysis from chest down
Which assessment findings relate to a cervical spinal cord injury? - ANSWER- -
paralysis from neck down
-impaired respiratory**
What are the manifestations of spinal shock? - ANSWER- -flaccid paralysis
-loss of sensory and motor fxn
-incontinence
What are the manifestations of autonomic dysreflexia? - ANSWER- -hypertension +
bradycardia
-HA
-flushing/diaphoresis
-blurred vision
What is the number one risk factor for a stroke? - ANSWER- hypertension
Which interventions are appropriate for a TIA? - ANSWER- -give aspirin
-education: TIA is temporary but needs immediate medical attention
What is the gold standard diagnostic test for a stroke? - ANSWER- noncontrast head
CT
What is the #1 assessment finding with a hemorrhagic stroke? - ANSWER-
"thunderclap" headache: comes on suddenly with no warning
What are the safety concerns with R sided vs L sided strokes? - ANSWER- -R:
impulsive or safety problems, such as impaired judgment
-L: emotional dysregulation
What are the main complications of hemorrhagic strokes (that she mentioned at least)?
- ANSWER- -homonymous hemianopsia: unilateral neglect (teach about looking around
+ caring for both sides of body)
-watch for stent occlusion or retroperitoneal hemorrhage
What is considered appropriate delegation for strokes? - ANSWER- -PCAs can help
with Pts who had a stroke a while ago & are stable now
-PCA should not be assigned to Pt who may have new symptoms
, What is the relationship between ischemic strokes and permissive HTN? - ANSWER- -
HTN is body's attempt to maintain cerebral perfusion
-therefore, only give BP meds if SBP >220
What is the purpose of the ventriculostomy system? - ANSWER- -gold standard for
measurement of ICP
-allows fluid to pour out based on set pressure
How do you calculate ICP? - ANSWER- CPP = MAP - ICP where MAP =
(SBP+(2DBP))/3
-less than 50 mmHg is associated with ischemia
What are some interventions to reduce ICP? - ANSWER- -align the head or elevate the
HOB
-cool the body temp down
-admin O2 to keep PaO2 > 85 mmHg
-avoid coughing/straining
What are the manifestations of Cushing's Triad? - ANSWER- -increased SBP
-decreased pulse
-decrease respirations (cheyne-stokes)
What are the differences between decorticate and decerebrate posturing? - ANSWER- -
decorticate: flexion in upper & extension in lower
-decerebrate: all 4 extremities are rigid = very bad!!
What are the two key indications that a patient may have a CSF leak? - ANSWER- -
CSF otorrhea: there is a ring on the Pt's pillow
-fluid tests positive for glucose
Which nursing action is contraindicated with a basilar skull fracture? - ANSWER-
placement of an NG tube
Which GCS scores correspond to minor, moderate, and severe injuries? - ANSWER- -
minor: 13-15
-mod: 9-12
-severe: 3-8
Which education points should be made for a concussion patient? - ANSWER- -watch
for lethargy or behavior changes within 2 weeks to 2 months after-
-watch for decreased short-term memory
-no driving, hot baths, or sports
Which assessment findings are important to monitor for with mannitol treatment? -
ANSWER- -HTN
Complete Solutions!!
Which assessment findings relate to a thoracic spinal cord injury? - ANSWER- -
paraplegia
-paralysis from chest down
Which assessment findings relate to a cervical spinal cord injury? - ANSWER- -
paralysis from neck down
-impaired respiratory**
What are the manifestations of spinal shock? - ANSWER- -flaccid paralysis
-loss of sensory and motor fxn
-incontinence
What are the manifestations of autonomic dysreflexia? - ANSWER- -hypertension +
bradycardia
-HA
-flushing/diaphoresis
-blurred vision
What is the number one risk factor for a stroke? - ANSWER- hypertension
Which interventions are appropriate for a TIA? - ANSWER- -give aspirin
-education: TIA is temporary but needs immediate medical attention
What is the gold standard diagnostic test for a stroke? - ANSWER- noncontrast head
CT
What is the #1 assessment finding with a hemorrhagic stroke? - ANSWER-
"thunderclap" headache: comes on suddenly with no warning
What are the safety concerns with R sided vs L sided strokes? - ANSWER- -R:
impulsive or safety problems, such as impaired judgment
-L: emotional dysregulation
What are the main complications of hemorrhagic strokes (that she mentioned at least)?
- ANSWER- -homonymous hemianopsia: unilateral neglect (teach about looking around
+ caring for both sides of body)
-watch for stent occlusion or retroperitoneal hemorrhage
What is considered appropriate delegation for strokes? - ANSWER- -PCAs can help
with Pts who had a stroke a while ago & are stable now
-PCA should not be assigned to Pt who may have new symptoms
, What is the relationship between ischemic strokes and permissive HTN? - ANSWER- -
HTN is body's attempt to maintain cerebral perfusion
-therefore, only give BP meds if SBP >220
What is the purpose of the ventriculostomy system? - ANSWER- -gold standard for
measurement of ICP
-allows fluid to pour out based on set pressure
How do you calculate ICP? - ANSWER- CPP = MAP - ICP where MAP =
(SBP+(2DBP))/3
-less than 50 mmHg is associated with ischemia
What are some interventions to reduce ICP? - ANSWER- -align the head or elevate the
HOB
-cool the body temp down
-admin O2 to keep PaO2 > 85 mmHg
-avoid coughing/straining
What are the manifestations of Cushing's Triad? - ANSWER- -increased SBP
-decreased pulse
-decrease respirations (cheyne-stokes)
What are the differences between decorticate and decerebrate posturing? - ANSWER- -
decorticate: flexion in upper & extension in lower
-decerebrate: all 4 extremities are rigid = very bad!!
What are the two key indications that a patient may have a CSF leak? - ANSWER- -
CSF otorrhea: there is a ring on the Pt's pillow
-fluid tests positive for glucose
Which nursing action is contraindicated with a basilar skull fracture? - ANSWER-
placement of an NG tube
Which GCS scores correspond to minor, moderate, and severe injuries? - ANSWER- -
minor: 13-15
-mod: 9-12
-severe: 3-8
Which education points should be made for a concussion patient? - ANSWER- -watch
for lethargy or behavior changes within 2 weeks to 2 months after-
-watch for decreased short-term memory
-no driving, hot baths, or sports
Which assessment findings are important to monitor for with mannitol treatment? -
ANSWER- -HTN
