NURSING 214 Medical-Surgical Nursing 1_ Test 2 (solution guide) Spring 2022

NURSING 214 Medical-Surgical Nursing 1 Med-surgical Nursing N214 Test 2 Questions & Answers Mod 4 Glascow coma scale is an neurological assessment tool nurses use. It has three categories. Name them? Ans - *eye opening *verbal response *motor response Mod 4 The glascow coma scale provides an easy way to describe a patient baseline mental status and to help detect and interpret changes from baseline findings. To use the scale test the patients ability to respond to verbal, motor and sensory stimulation and grade your finding according to the scale. If the patient is alert , follows simple command and is orientated to person, place and time his score will be? Ans - 15 points the highest possible score. Mod 4 A low score in one or more categories may signal an impending neurological crisis. A total score of 7 or less indicates? Ans - severe neurological damage Mod 4 What is decorticate posturing? Ans - posturing toward the spinal cord indicating neurological damage. This is associated lesion of the corticospinal tract near the cerebral hemisphere, midbrain dysfunction. Legs are stiffly extended internally rotated and feet plantar flexed. Mod 4 What is decerbrate posture? Ans - Hand posturing away from the body indicating neurological damage. This way score less on the Glasgow coma scale. associated with a lesion of the diencephalon, pons or midbrain, usually. Ankles and toes are flexed. Mod 4 What does PERRLA stand for? Ans - Pupils equally round and reactive to light and accommodations. Mod 4 What is consensual response? Ans - this means when you shine a light in one eye the other eye pupil will constrict too. This is an appropriate response. Mod 4 Nurses assess motor strength in all extremities a score of 0 means Ans - no muscle contraction Mod 4 A score of 5 equals? Ans - full range of motion Mod 4 Your patient cannot express themselves in speech, writing or signs. The cannot comprehend spoken or written word. You know this is Ans - aphasia/resulting from brain disease or trauma. Mod 4 Sensory aphasia is Ans - receptive Loss of ability to comprehend spoken word auditory lost the ability to understand sounds visual-lost of the ability to understand printed or written figures (like an address, phone no.) Mod 4 What is Broca's aphasia? Ans - speech is reduced. They can utterance of about four words.Understand speech relatively well. reading and writing is limited. Mod 4 What is wrenches aphasia? Ans - ability to grasp the meaning of the spoken word is impaired. Ability to speak is not impaired but the flow of words is often not appropriate and broken. Reading and writing is severely impaired. Mod 4 Your patient calls you in and just keep saying I want blah blah. You know this is? Ans - broca's aphasia Mod 4 You tell your patient to lift up their hands and they just stare at you. You know this is ? Ans - Wernikes aphasia Mod 4 Your patient cannot express in writing or making sounds or speaking you know this is Ans - motor/expressive aphasia Mod 4 What are some nursing interventions for a patient who is experiencing aphasia? Ans - *provide for picture recognition (memory)/pictures trigger memories from storage areas of the brain that are different from those used in speech. *structure the teach methods according to the patients organization of information/rationale: the patients organization of information will determine the logical sequence of learning for him or her. *Monitor the pt behavior during therapy/rationale:the pt mahout agitated and frustrated during therapy which signals the need to stop the session. *encourage the patient to use previous learned skills/rationale: distant memories may remain in tact and this gives the patient some self control *Assit the family to understand that assertive behavior may be the result of poor memory/rationale:aggressive or combative behavior by the patient may signal a threat to self esteem from memory loss. *request a neuropsychology consult to identify what areas need work. Mod 4 Your patient has trouble swelling or chewing food. As a nurse you know this is? Ans - dysphagia Mod 4 The big risk with dysphagia is? Ans - aspiration Mod 4 Patients with dysphagia often don't get enough food or fluids and this means they are? Ans - dehydrated constipated Mod 4 Your patient has slurred speech you know this is? Ans - dysarthria Mod 4 Dysarthria patient needs what asap for chance of recovery? Ans - speech pathologist Mod 4 Your patient asks you to read a note because they cannot understand written language this is Ans - alexia problems with written language. Mod 4 Your patient just can't find the right words to express what they are trying to communicate. This is? Ans - anomia Mod 4 Your patient asks you to write a phone no. down for them because they no longer can. This is? Ans - agraphia Mod 4 You patient cannot dial the phone you know this is? Ans - apraxia loss of ability to carry out a purposeful motor activity. Mod 4 You notice your patient is walking funny gait and has seemed to lose their balance a lot this is Ans - ataxia-gait disturbance or loss of balance, possible brainstem or cerebellum danage Mod 4 Your patient can no longer read or write? Ans - agnosia/general term for loss of sensory comprehension, may include an inability to write, comprehend reading,material, or use an object correctly. Mod 4 What are modifiable risk factors for CVA? Ans - *smoking *HTN *illegal drug use *atherosclerotic disease (high fat diet) *sedentary lifestyle *diabetes *heavy alcohol use Mod 4 What are non modifiable risk factors of a CVA? Ans - *trauma *sickle cell anemia *african American, Hispanic, American Indian *male *older age *atrial fibulation *valvular heart disease. Mod 4 What are most ischemic stroke associated with? Ans - atherosclerosis Mod 4 What is a TIA? Ans - Transient ischemia attack is a temporary interruption of blood flow to the brain, that usually clears within 12 to 24 hours. Its usually considered a warning sign of an impending thrombotic stoke. Mod 4 What is the percentage of TIA that turns into CVA? Ans - 50-80% Mod 4 What age makes a big difference in TIA's? Ans - After 50 the incidence of tia resulting in stroke greatly increases. Mod 4 What men are the highest risk group? Ans - Black men Mod 4 What happens is a tia? Ans - patient loses some function: unilateral blindness, unilateral weakness or numbness, speech deficit or others but the regain full function quickly. Mod 4 What is a thrombus? Ans - clot Mod 4 What is an embolus? Ans - moving clot which can lodge in heart, lungs or brain. Mod 4 What is another name for TIA's? Ans - mini stroke or silent stroke Mod 4 What is an ischemic stroke? Ans - blockage of a cerebral artery by a thrombus or embolus. A stoke is a sudden interruption of circulation in one or more blood vessels to the brain. During a stroke the brain tissue fails to receive adequate oxygenation resulting in serious tissue damage or necrosis. Usually associated with development of atherosclerosis. Mod 4 What is the biggest factor in a stroke relating to recovery? Ans - the speed at which circulation is restored determines the patients chance of recovery. Mod 4 Which stroke is more common ischemic or hemorrhagic? Ans - ischemic Mod 4 Which stroke is more deadly ischemic or hemorrhage? Ans - hemmorhagic Intraparenchymal hemorrhage Intraparenchymal hemorrhage occurs when a blood vessel to the brain ruptures and bleeds, causing rapidly increasing pressure in the brain. Subarachnoid hemorrhage A subarachnoid hemorrhage occurs when an aneurysm (blister-like bulge of the wall of an artery) ruptures over the surface of the brain, creating an explosive burst of blood between the brain and the skull, causing a build-up of pressure that damages the brain Mod 4 Where is the most common site for a thromolitoc stoke? Ans - bifurcation of the common artery and vertebral artery. Mod 4 Where is most embolic strokes start from? Ans - *heart and afib, ischemic heart disease or rheumatic heart disease. *Plaque breaking off the carotid sinus or internal carotid artery ( carotid US and Bruits) Mod 4 What is something we can do as nurses to maybe prevent a stroke? Ans - *listen to carotid arteries for bruits *get an ultrasound of carotid arteries if we suspect something. Mod 4 Where is the most common spot for an embolic stroke Ans - MCA /middle cerebral artery Mod 4 Patient came into the hospital via ER after snorting cocaine and complains of severe headache and high blood pressure. It may be Ans - hemorrhagic stroke from cocaine abuse (this cause their blood pressure to spike up suddenly) Mod 4 What happens it a hemorrhagic stroke? Ans - *an artery in the brain leaks, rapidly reducing the blood supply to the tissue served by the artery. Blood accumulates deep within the brain, causing even greater damage by further compromising neural tissue. Mod 4 What can cause a hemorrhagic stroke? Ans - *severe hypertension *ruptured aneurysm *rupture of an arteriovenous malformation (AVM) *cocaine abuse Mod 4 What is an abnormal ballooning or blister along an artery called? Ans - aneurysm Mod 4 What is a secular aneurysm? Ans - this is a weak spot in an artery wall, it is the most common aneurysm. Mod 4 Congenital aneurysm means you were? Ans - born with it. Mod 4 What is the definition of an aneurysm? Ans - a permanent localized dilation of an artery which enlarges the artery to at least two times its normal diameter. The can rupture and cause bleeding into the subarachnoid space, the ventricles and the intracerbral tissue. Mod 4 What is an artery that has the whole circumference dilation called? Ans - fusiform What is called when only part of the vessel has an outpouching in the only one part of the artery? Ans - saccular Mod 4 What is a true aneurysm? Ans - its when the arterial wall has become weakened by congenital or acquired problems. Mod 4 What is a false aneurysm? Ans - this is when a vessel injury or trauma occurs to all three layers of the arterial wall. Mod 4 What is it when you are born with a spaghetti-like mass, with thin walled dilate vessels that is though of as a short circuit where blood does not go into the tissues but is pumped through the shunt and back to the heart without giving nutrients to the tissues? Ans - AVM-arterioVenous Malformation Mod 4 What are some signs and symptoms of a stroke? Ans - *blurred vision/double vision/blindness in one eye/tunnel vision *weakness on one side (unilateral) *gait disturbance *numbness one sided (unilateral) *aphasia *dysarthria (slurred speech) Mod 4 What is FAST in Strokes? Ans - Facial weakness Arm weakness Speech problems Time to call 911 Mod 4 Flaccid one side of a face is a sign of a Ans - stroke Mod 4 A stroke is a ? Ans - medical emergency/get to the hospital immediately. Time is everything in a ischemic stroke being reversed. Mod 4 The brain cannot store? Ans - glucose or oxygen, so if there is a block everything after the block is dying. Mod 4 Patient has signs of a stroke find out if they are on? Ans - blood thinners Mod 4 what labs will you need to order right away? Ans - Prothrombin time (PT) Partial Thromboplastin time (PTT) International Normalized Ration (INR) May provide evidence that a hemorrhagic stroke has occurred. Mod 4 What do you do when testing for stroke? Ans - History and physical When did the symptoms start (important for ischemic treatment) Medical history Medications (blood thinners??) National Institutes of Health Stroke Scale (long) Mod 4 What test will they need immediately to tell us if they had an infarction or ischemia? Ans - CT/takes approximately 10 minutes to scan the entire brain. Mod 4 What is better an MRI or CT? Ans - MRI is better but it takes a lot longer. If patient is allergic to iv contrast, shellfish, or iodine they will need an MRI. Mod 4 The patient has had a ischemic stroke the goal is to get them alteplase within Ans - the first three hours. Mod 4 If patient cannot take alteplase (tPA) Ans - aspirin or heparin Mod 4 Watch a patients cheek if one side balloons with respiration thats the side of ? Ans - the stroke. Mod 4 Nursing interventions for stroke? Ans - *administer stool softners don't want them to strain *maintain fluid and electrolyte balance *check swallow reflex !!!! *ensure adequate nutrition *watch for signs of pulmonary embolism *chest pain, sob, dusky color, changed sensorium *mouth care *turn patient every 2 hours to prevent pneumonia *meticulous eye care with sterile normal saline *help with range of motion *monitor for neurologic changes or complications associated with stroke and its treatment Mod 4 Maintain communication with patient. If he's aphasic set up a simple method of? Ans - communicating Mod 4 Stroke teaching tips for patient and family are? Ans - *teach patient to comb hair, wash and dress if needed *obtain appliances such as walker, grab bars for tub or toilet and ramps as needed. *encourage pt to be speech therapy *rehabilitation *take aspirin as ordered/watch for gi bleed *watch for another stroke *severe headache/drowsiness/confusion/dizziness *keep all follow up apps Mod 4 no. 1 sign of a stroke is a change in ? Ans - LOC Mod 4 How much rtPA can you give? Ans - 0.9mg per kg of recombinant tissue plasminogen activator Mod 4 The maximum rtPA you can give to anyone is Ans - 90mg Mod 4 How often will we perform neuro-assessments on a patient getr tPA? Ans - every 15 minutes during infusion and then every 30 minutes Mod 4 Patient will be admitted to? Ans - ICU Mod 4 Give them a bolus of 10% of the rtPA over? Ans - one minute Mod 4 If this patient has a bp over 180/105 they will also need? Ans - bp meds Mod 4 During rtPA administration do not? Ans - place invasive lines/they will already have an IV Discontinue infusion if patient reports headache, has severe HTN, nausea, vomiting, or bleeding. Prepare for STAT head CT Mod 4 After 24 hours we need to get a follow up Ans - CT scan prior to starting anti platelet or anticoagulant drugs. Mod 4 Major complications of a stroke is? Ans - Increased ICP during the first 72 hours Mod 4 How should you position a patient with ICP? Ans - head of bed at 30 degrees/never lye them flat HOB at 30 degrees Head in midline, neutral position to help promote venous drainage Avoid extreme head/neck flexion Avoid cluster nursing care Hyperoxygenating Pt before suctioning to prevent cerebral dilation Quiet environment Low lights Watch BP closely Watch for fever Mod 4 Hemorrhagic stroke what do we do? Ans - watch and wait to see if the body absorbs blood on its own. These are almost always deadly. Mod 4 What intervention can we do for a hemmorhagic stroke? Ans - surgery??? Mod 4 Big thing with stroke is rehabilitation afterwards. Ans - *exercise therapy *use of assistive devices *swollow evaluation *speech therapy *disturbed thought process from brain damage *provide pictures for recognition *memory training *find a way to communicate with them if possible Mod 4 How does aspirin work? Ans - prevents blood clotting by reducing platelet adhesiveness. Mod 4 Sometime they use ? Ans - antiseizure meds neuorprotective drugs (calcium channel blockers prevent cerebral vasospasm-smooth muscle relaxer Mod 4 Unequal pupils means increase ICP and damage to what cranial nerve? Ans - third cranial nerve Mod 4 Increase ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in what else? Ans - systolic pressure which reflects the additional pressure need to profuse the brain. tt increase the pressure on the vagus nerve which thus produces bradycardia and it cause an increase in temperature from hypothalamic damage. Mod 4 A client is being monitored for a TIA . She is orientated is orientated , can open her eyes spontaneously and follows commands. What is her Glasgow coma scale? Ans - 15 Mod 4 The nurse is teaching the client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client udrstands how to take the drug. Select all that apply Ans - *3-4 days for warfarin to achieve maximum dosage *effects of the drug continue for 4-5 days after last dose *I should have my blood tested periodically. Mod 4 Your giving oral care to a patient who had a stroke what position should they be in and what must be readily available? Ans - *lateral position to avoid aspiration *suction Mod 4 A patient arrives at the emergency room with a CVA what is vital information we need? Ans - when did it happen/rtPA needs to be given within three hours of incident if possible Mod 4 The client has an ischemic stroke and is treated with rtPA. What vital do you need to watch diligently? Ans - control of blood pressure is critical during the first 24 hours after treatment because of an intra-cerebral hemorrhage is the major adverse effect of thrombolytic therapy. Mod 4 For a client who is experiencing expressive aphasia which nursing intervention is most helpful in promoting communication? Ans - *using a picture board Mod 4 Your helping a patient with dysphagia with lunch . Make sure the patient is in what position? fluids are ___? Should they have food and what else? Ans - high fowlers position thickened liquids food eaten on unaffected side distractions free zone, they have to concentrate on eating and swallowing. Mod 4 What is the expected outcome of thrombolytic drug therapy for a stroke? Ans - dissolved emboli Mod 6 What does the lens of the eye do? Ans - Refracts and focuses light on the retina. Mod 6 What does the retina do? Ans - receives information and transmits to the brain for processing. Mod 6 What makes vision possible? Ans - photoreceptor neurons rods and cones. Mod 6 Rods respond to Ans - low intensity light and shades of gray. Mod 6 ____are responsible for bright light and are responsible for snap, color vision. Ans - Cons Mod 6 The ___allows provides the sharpest vision allowing us to read and recognize faces. Ans - macula Mod 6 Unequal pupil usually means? Ans - nuero damage Mod 6 What is direct response? Ans - That is when you shine a light in the pupil and it constricts. Mod 6 What is consenual response? Ans - That is when the opposite pupil does the same thing. Mod 6 A pupil that doesn't react to light ( a fixed pupil) can be a? Ans - ominous neurological sign. Mod 6 Six cardinal signs of gaze are testing cranial nerves? Ans - 3, 4, and 6 Mod 6 Constriction of retinal vessels is a sign of ? Ans - hypertension Mod 6 What is when you have the perfect refraction of the eye with the lens at rays form a distance 6m or more are focused into a sharp image on the retina? Ans - emmetropia Continues...............