NUR 445. Final Exam
What is the nurses role while caring for a patient undergoing genetic testing? - answer
Obtain and assess family history (assess risk of certain diseases, establish pattern of
inheritance, ID family members at risk and calculate risk)
Assess patients understanding of genetic info and factors r/t health risks
Refer for risk assessment when a hereditary disease or disorder is suspected
Determine if genetic testing has been performed and if other family members are
effected
educate patient and family about GINA passed in 2008
Obtain consent and provide support to patients
What interventions must a preoperative nurse complete prior to a patient being taken to
the OR? - answer Baseline head to toe assessment
Medications: home med list and when last taken (beta blockers can be taken up until
day of, but anticoagulants may be held)
Obtain informed consent, assess for capability to consent, witness/verify
Assess allergies and comorbid conditions
Assess family and genetic hx for complications with anesthesia, latex allergy, malignant
hyperthermia
Administer preanesthetic meds, maintain preop record, transporting patient to surgical
area, attending to family needs
Patient education: educate patient regarding surgical process discharge plan, meds,
resources, etc
What criteria must a patient meet for consent? - answer18 years old (unless
emancipated minor)
Autonomous and informed
Competent patient: not cognitively impaired, mentally ill, or neurologically incapacitated
What are potential complications that can occur during an operation? -
answerAnesthesia awareness
Anaphylaxis
Hypothermia
Malignant hyperthermia
What are priority assessments for a post op nurse? - answerPatent airway and
cardiovascular stability
VS
Pain relief
Control of nausea and vomiting
, What discharge criteria does the patient need to meet, in order to be discharged from
the PACU? - answerStable BP, adequate respiratory function and O2 sat compared to
baseline
Aldridge score between 7 and 10
What early assessment findings would make a nurse suspect a patient has increased
ICP? - answerDisorientation, confusion, pupil changes, lethargy, weakness, headache
What are some late assessment findings that would make a nurse suspect a patient has
increased ICP? - answerVS changes, projectile vomiting, loss of reflexes
what are some potential complications associated with increased ICP? - answerBrain
herniation
Diabetes Insipidus
syndrome of inappropriate antidiuretic hormone (SIADH)
What are some assessment findings that would make the nurse believe diabetes
Insipidus has occurred? - answerExcessive urine output
Tx: give fluids, monitor and replace electrolytes, synthetic vasopressin
What are some assessment findings that would make the nurse believe SIADH has
occurred? - answerFluid overload s/s
Tx: give diuretics
What assessment findings make a nurse suspect a patient is having a CVA? -
answerNumbness or weakness of the face, arm, leg - esp. unilaterally
Confusion or a change in mental status
Trouble speaking or understanding speech
Visual disturbances
Difficulty walking, dizziness, loss of balance
Sudden severe headache
What treatments should the nurse anticipate for an ischemic stroke: -
answerRecombinant t-PA if patient meets criteria. If not t-PA, other anticoagulant
therapy is initiated. Possible surgery to correct issues that may have caused CVA
What treatments should the nurse anticipate for a hemorrhagic stroke? - answerBed
rest for brain recovery, monitor for re-bleeding, manage HTN and pain, surgical
management possible for evacuation of blood in the brain, coiling aneurysms to prevent
rupture. Monitor GSC and for changes in mental exam.
What assessments and nursing interventions are implemented immediately post stroke?
- answerNIH scales q hour, q2hour, q 4 hour; CT scan, potentially TPA
Craniotomy to evacuate hemorrhagic stroke, ICPmonitoring
What is the nurses role while caring for a patient undergoing genetic testing? - answer
Obtain and assess family history (assess risk of certain diseases, establish pattern of
inheritance, ID family members at risk and calculate risk)
Assess patients understanding of genetic info and factors r/t health risks
Refer for risk assessment when a hereditary disease or disorder is suspected
Determine if genetic testing has been performed and if other family members are
effected
educate patient and family about GINA passed in 2008
Obtain consent and provide support to patients
What interventions must a preoperative nurse complete prior to a patient being taken to
the OR? - answer Baseline head to toe assessment
Medications: home med list and when last taken (beta blockers can be taken up until
day of, but anticoagulants may be held)
Obtain informed consent, assess for capability to consent, witness/verify
Assess allergies and comorbid conditions
Assess family and genetic hx for complications with anesthesia, latex allergy, malignant
hyperthermia
Administer preanesthetic meds, maintain preop record, transporting patient to surgical
area, attending to family needs
Patient education: educate patient regarding surgical process discharge plan, meds,
resources, etc
What criteria must a patient meet for consent? - answer18 years old (unless
emancipated minor)
Autonomous and informed
Competent patient: not cognitively impaired, mentally ill, or neurologically incapacitated
What are potential complications that can occur during an operation? -
answerAnesthesia awareness
Anaphylaxis
Hypothermia
Malignant hyperthermia
What are priority assessments for a post op nurse? - answerPatent airway and
cardiovascular stability
VS
Pain relief
Control of nausea and vomiting
, What discharge criteria does the patient need to meet, in order to be discharged from
the PACU? - answerStable BP, adequate respiratory function and O2 sat compared to
baseline
Aldridge score between 7 and 10
What early assessment findings would make a nurse suspect a patient has increased
ICP? - answerDisorientation, confusion, pupil changes, lethargy, weakness, headache
What are some late assessment findings that would make a nurse suspect a patient has
increased ICP? - answerVS changes, projectile vomiting, loss of reflexes
what are some potential complications associated with increased ICP? - answerBrain
herniation
Diabetes Insipidus
syndrome of inappropriate antidiuretic hormone (SIADH)
What are some assessment findings that would make the nurse believe diabetes
Insipidus has occurred? - answerExcessive urine output
Tx: give fluids, monitor and replace electrolytes, synthetic vasopressin
What are some assessment findings that would make the nurse believe SIADH has
occurred? - answerFluid overload s/s
Tx: give diuretics
What assessment findings make a nurse suspect a patient is having a CVA? -
answerNumbness or weakness of the face, arm, leg - esp. unilaterally
Confusion or a change in mental status
Trouble speaking or understanding speech
Visual disturbances
Difficulty walking, dizziness, loss of balance
Sudden severe headache
What treatments should the nurse anticipate for an ischemic stroke: -
answerRecombinant t-PA if patient meets criteria. If not t-PA, other anticoagulant
therapy is initiated. Possible surgery to correct issues that may have caused CVA
What treatments should the nurse anticipate for a hemorrhagic stroke? - answerBed
rest for brain recovery, monitor for re-bleeding, manage HTN and pain, surgical
management possible for evacuation of blood in the brain, coiling aneurysms to prevent
rupture. Monitor GSC and for changes in mental exam.
What assessments and nursing interventions are implemented immediately post stroke?
- answerNIH scales q hour, q2hour, q 4 hour; CT scan, potentially TPA
Craniotomy to evacuate hemorrhagic stroke, ICPmonitoring
