NSG 233 Med Surg III Exam 2 – Questions With
Accurate Solutions
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Terms in this set (121)
What is the cardinal behavioral sign of Bizarre or irrational behavior.
a frontal lobe traumatic brain injury?
What is the cardinal neurologic sign of Amnesia or disorientation.
a temporal lobe traumatic brain injury?
Upon discharge, which s/s would you - decreased LOC.
teach the patient to return to the - worsening headache.
emergency department if they begin - Dizziness.
experiencing? - Seizures.
- Abnormal pupil response.
- vomiting.
- irritability.
- slurred speech.
- weakness or numbness of the extremities.
What are the three cardinal signs of 1. coma.
brain death? 2. absence of reflexes.
3. apnea.
What GCS score indicates a severe A score of 3-8.
traumatic brain injury?
What are the three signs of the 1. Bradycardia (decreased heart rate).
Cushing's Triad and what do they 2. Widening pulse pressure (SBP is rising).
indicate? 3. Irregular respirations.
- Cushing's Triad indicates increased intracranial
pressure.
,What is a common electrolyte Hyponatremia (low sodium).
imbalance in patients who experience
a TBI? Normal sodium levels are 135-145 mEq/L.
What are some nursing interventions - Maintain a patent airway.
for a TBI? - monitor neurologic function (neuro checks).
- monitor vitals (look for Cushing's triad).
- POSITION HOB AT 30 DEGREES WITH THE NECK
IN A NEUTRAL POSITION TO PROTECT C-SPINE.
- assess motor function.
- monitor for fluid and electrolyte imbalances,
especially sodium.
- promote adequate nutrition.
- maintain thermoregulation.
- maintain skin integrity.
- early administration of anticonvulsants.
- maintain cerebral perfusion pressure.
What can hyponatremia cause? What Seizures!
precautions do we need to place our
patient on because of this? Seizure precautions.
What should cerebral perfusion Above 50 mmHg.
pressure be maintained at?
What are three common symptoms for 1. agitation.
a patient coming out of a coma? 2. restlessness.
3. incontinence.
May also experience lethargy and stupor.
What do unilaterally dilated and The development of a hematoma, with subsequent
poorly responding pupils indicate? pressure on the third cranial nerve due to shifting of
the brain.
What is the medication Phenytoin Used to control seizures!
(Dilantin) used for?
, What is an important patient teaching Oral contraceptives are less effective when taking
point for a young woman who is this medication. Therefore, you should use other
taking Phenytoin? forms of contraception in addition to oral
contraceptives if you choose to be sexually active.
What are the side effects of Phenytoin S/E: nausea, vomiting, drowsiness, lethargy, and
and what are some patient teaching ataxia.
points?
Pt teaching: maintain good oral hygiene to prevent
gum disease! Also, use contraception, oral
contraceptives are less effective when taking
Phenytoin.
What is Propofol and what is it used It is an IV anesthetic (sedative/hypnotic).
for?
Used for induction and maintenance of general
anesthesia. It provides smooth hypnosis in less than
one minute.
It blocks the perception of pain by producing
amnesia, euphoria, and hypnosis. However, it does
not provide analgesia.
What are the two most common uses 1. used to sedate patients who are placed on
of Propofol for TBI patients? mechanical ventilation.
2. suppresses laryngeal reflexes, making it a suitable
choice when inserting supraglottic airway devices.
Explain the difference between Decorticate: hands turned inwards, arms folded in,
decorticate and decerebrate feet and legs extended out.
posturing. Which one is worse?
Decerebrate: arms extended with wrists rotated
outwards, legs extended with feed internally rotated.
Decerebrate is worse!!!
Accurate Solutions
Save Groups
Terms in this set (121)
What is the cardinal behavioral sign of Bizarre or irrational behavior.
a frontal lobe traumatic brain injury?
What is the cardinal neurologic sign of Amnesia or disorientation.
a temporal lobe traumatic brain injury?
Upon discharge, which s/s would you - decreased LOC.
teach the patient to return to the - worsening headache.
emergency department if they begin - Dizziness.
experiencing? - Seizures.
- Abnormal pupil response.
- vomiting.
- irritability.
- slurred speech.
- weakness or numbness of the extremities.
What are the three cardinal signs of 1. coma.
brain death? 2. absence of reflexes.
3. apnea.
What GCS score indicates a severe A score of 3-8.
traumatic brain injury?
What are the three signs of the 1. Bradycardia (decreased heart rate).
Cushing's Triad and what do they 2. Widening pulse pressure (SBP is rising).
indicate? 3. Irregular respirations.
- Cushing's Triad indicates increased intracranial
pressure.
,What is a common electrolyte Hyponatremia (low sodium).
imbalance in patients who experience
a TBI? Normal sodium levels are 135-145 mEq/L.
What are some nursing interventions - Maintain a patent airway.
for a TBI? - monitor neurologic function (neuro checks).
- monitor vitals (look for Cushing's triad).
- POSITION HOB AT 30 DEGREES WITH THE NECK
IN A NEUTRAL POSITION TO PROTECT C-SPINE.
- assess motor function.
- monitor for fluid and electrolyte imbalances,
especially sodium.
- promote adequate nutrition.
- maintain thermoregulation.
- maintain skin integrity.
- early administration of anticonvulsants.
- maintain cerebral perfusion pressure.
What can hyponatremia cause? What Seizures!
precautions do we need to place our
patient on because of this? Seizure precautions.
What should cerebral perfusion Above 50 mmHg.
pressure be maintained at?
What are three common symptoms for 1. agitation.
a patient coming out of a coma? 2. restlessness.
3. incontinence.
May also experience lethargy and stupor.
What do unilaterally dilated and The development of a hematoma, with subsequent
poorly responding pupils indicate? pressure on the third cranial nerve due to shifting of
the brain.
What is the medication Phenytoin Used to control seizures!
(Dilantin) used for?
, What is an important patient teaching Oral contraceptives are less effective when taking
point for a young woman who is this medication. Therefore, you should use other
taking Phenytoin? forms of contraception in addition to oral
contraceptives if you choose to be sexually active.
What are the side effects of Phenytoin S/E: nausea, vomiting, drowsiness, lethargy, and
and what are some patient teaching ataxia.
points?
Pt teaching: maintain good oral hygiene to prevent
gum disease! Also, use contraception, oral
contraceptives are less effective when taking
Phenytoin.
What is Propofol and what is it used It is an IV anesthetic (sedative/hypnotic).
for?
Used for induction and maintenance of general
anesthesia. It provides smooth hypnosis in less than
one minute.
It blocks the perception of pain by producing
amnesia, euphoria, and hypnosis. However, it does
not provide analgesia.
What are the two most common uses 1. used to sedate patients who are placed on
of Propofol for TBI patients? mechanical ventilation.
2. suppresses laryngeal reflexes, making it a suitable
choice when inserting supraglottic airway devices.
Explain the difference between Decorticate: hands turned inwards, arms folded in,
decorticate and decerebrate feet and legs extended out.
posturing. Which one is worse?
Decerebrate: arms extended with wrists rotated
outwards, legs extended with feed internally rotated.
Decerebrate is worse!!!
