NUR 508 Final Exam Questions and answers Updated 100% PASS

NUR 508 Final Exam Questions and answers
Updated 100% PASS
Which assessment findings relate to a thoracic spinal cord injury?
II! II! II! II! II! II! II! II! II!




-paraplegia
-paralysis from chest down II! II! II!




Which assessment findings relate to a cervical spinal cord injury?
II! II! II! II! II! II! II! II! II!




-paralysis from neck down II! II! II!




-impaired respiratory** II!




What are the manifestations of spinal shock?
II! II! II! II! II! II!




-flaccid paralysis II!




-loss of sensory and motor fxn
II! II! II! II! II!




-incontinence

What are the manifestations of autonomic dysreflexia?
II! II! II! II! II! II!




-hypertension + bradycardia II! II!




-HA
-flushing/diaphoresis
-blurred vision II!




What is the number one risk factor for a stroke?
II! II! II! II! II! II! II! II! II!




hypertension

Which interventions are appropriate for a TIA?
II! II! II! II! II! II!




-give aspirin
II!




-education: TIA is temporary but needs immediate medical attention
II! II! II! II! II! II! II! II!




What is the gold standard diagnostic test for a stroke?
II! II! II! II! II! II! II! II! II!




noncontrast head CT II! II!




What is the #1 assessment finding with a hemorrhagic stroke?
II! II! II! II! II! II! II! II! II!




"thunderclap" headache: comes on suddenly with no warning II! II! II! II! II! II! II!




What are the safety concerns with R sided vs L sided strokes?
II! II! II! II! II! II! II! II! II! II! II!

, -R: impulsive or safety problems, such as impaired judgment
II! II! II! II! II! II! II! II!




-L: emotional dysregulation
II! II!




What are the main complications of hemorrhagic strokes (that she mentioned at least)?
II! II! II! II! II! II! II! II! II! II! II! II!




-homonymous hemianopsia: unilateral neglect (teach about looking around + caring for both II! II! II! II! II! II! II! II! II! II! II!




sides of body)
II! II! II!




-watch for stent occlusion or retroperitoneal hemorrhage
II! II! II! II! II! II!




What is considered appropriate delegation for strokes?
II! II! II! II! II! II!




-PCAs can help with Pts who had a stroke a while ago & are stable now
II! II! II! II! II! II! II! II! II! II! II! II! II! II! II!




-PCA should not be assigned to Pt who may have new symptoms
II! II! II! II! II! II! II! II! II! II! II!




What is the relationship between ischemic strokes and permissive HTN?
II! II! II! II! II! II! II! II! II!




-HTN is body's attempt to maintain cerebral perfusion
II! II! II! II! II! II! II!




-therefore, only give BP meds if SBP >220 II! II! II! II! II! II! II!




AD

What is the purpose of the ventriculostomy system?
II! II! II! II! II! II! II!




-gold standard for measurement of ICP
II! II! II! II! II!




-allows fluid to pour out based on set pressure II! II! II! II! II! II! II! II!




How do you calculate ICP?
II! II! II! II!




CPP = MAP - ICP where MAP = (SBP+(2DBP))/3
II! II! II! II! II! II! II! II!




-less than 50 mmHg is associated with ischemia
II! II! II! II! II! II! II!




What are some interventions to reduce ICP?
II! II! II! II! II! II!




-align the head or elevate the HOB
II! II! II! II! II! II!




-cool the body temp down II! II! II! II!




-admin O2 to keep PaO2 > 85 mmHg II! II! II! II! II! II! II!




-avoid coughing/straining II!




What are the manifestations of Cushing's Triad?
II! II! II! II! II! II!




-increased SBP II!




-decreased pulse II!




-decrease respirations (cheyne-stokes) II! II!




What are the differences between decorticate and decerebrate posturing?
II! II! II! II! II! II! II! II!