NSG 4100 EXAM 4 QUESTIONS AND ANSWERS A+
GRADED. Buy Quality Materials!
Positive Kernig sign
Pt. lies flat and thigh flexed on abdomen - leg unable to completely extend
Positive Brudzinski Sign
When pt. neck is flexed →knees & hips flex up from straight
*More sensitive indicator than kernig
Nursing Interventions ICP
↓ Noise/Light
Cluster care
Limit visitors
Pain meds
Seizure precautions
Monitor LOC, Labs, Urine output
Drain CSF (shunt)
Priority Nursing Intervention Huntington's w/pneumonia
Respiratory support:
Incentive Spirometer
TCDB (turn cough deep breathe)
Humidified O2
CPT
Myasthenia gravis treatment
Pyridostigmine to improve muscle strength & ADL's
Myasthenia Gravis complications missed doses
Myasthenic Crisis:
Respiratory failure; neuromuscular respiratory failure may require intubation
Most common clinical manifestations Fibromyalgia
Trigger point pain
Difficulty sleeping
Nursing Education to prevent injury MS
Falls Prevention:
Walk with feet apart to widen base
Watch feet while walking
Gait training
, Assistive devices (walker, cane, braces
Amyotrophic lateral sclerosis (ALS) complication
Neuromuscular weakness resulting in respiratory failure that may require intubation
Functional ability by Level of Cord Injury
C1 - C3 possible C4
Completely dependent for dressing, eating, elimination
Electric wheelchair
Functional ability by Level of Cord Injury
C4 - C5
Maximal Assistance elimination
Independent w/ assistance eating/dressing
Functional ability by Level of Cord Injury
C6
Bowel control
Minimal assist in transfers & wheelchair
Functional ability by Level of Cord Injury
T11 +
Ambulatory w/assist
Autonomic Dysreflexia
Exaggerated autonomic response to stimulation;
Triggers:
wrinkle in sheets, full bladder pressure, etc.
Most common cause of Autonomic Dysreflexia
SCI spinal cord injury
T6 and above
What is seen Guillian-Barre?
CSF?
Muscle weakness, diminished reflexes, demyelination of nerves
Protein in CSF
Gullian-Barre nursing interventions
Medical emergency due to rapid progression to respiratory failure:
Maintain Respiratory & Improve: TCDB, IS, CPT
bulbar weakness impairs ability to swallow & clear secretions - suctioning
Enhance Mobility: DVT, pressure ulcers
Nutrition: prevent ileus, IV fluids
Communication
Decrease fear & Anxiety
Order of Priority Intervention in Burn Patient
1. Obtain VS & hemodynamic status
2. Calculate TBSA affected
3. Calculate Parkland Formula
4. Dress wound w/sterile gauze
Third Degree Burns (Full Thickness)
Can go into shock
Myoglobin urea (muscle breakdown →stuck in kidneys →hematuria)
Common in older adults due to ↓ sensation
GRADED. Buy Quality Materials!
Positive Kernig sign
Pt. lies flat and thigh flexed on abdomen - leg unable to completely extend
Positive Brudzinski Sign
When pt. neck is flexed →knees & hips flex up from straight
*More sensitive indicator than kernig
Nursing Interventions ICP
↓ Noise/Light
Cluster care
Limit visitors
Pain meds
Seizure precautions
Monitor LOC, Labs, Urine output
Drain CSF (shunt)
Priority Nursing Intervention Huntington's w/pneumonia
Respiratory support:
Incentive Spirometer
TCDB (turn cough deep breathe)
Humidified O2
CPT
Myasthenia gravis treatment
Pyridostigmine to improve muscle strength & ADL's
Myasthenia Gravis complications missed doses
Myasthenic Crisis:
Respiratory failure; neuromuscular respiratory failure may require intubation
Most common clinical manifestations Fibromyalgia
Trigger point pain
Difficulty sleeping
Nursing Education to prevent injury MS
Falls Prevention:
Walk with feet apart to widen base
Watch feet while walking
Gait training
, Assistive devices (walker, cane, braces
Amyotrophic lateral sclerosis (ALS) complication
Neuromuscular weakness resulting in respiratory failure that may require intubation
Functional ability by Level of Cord Injury
C1 - C3 possible C4
Completely dependent for dressing, eating, elimination
Electric wheelchair
Functional ability by Level of Cord Injury
C4 - C5
Maximal Assistance elimination
Independent w/ assistance eating/dressing
Functional ability by Level of Cord Injury
C6
Bowel control
Minimal assist in transfers & wheelchair
Functional ability by Level of Cord Injury
T11 +
Ambulatory w/assist
Autonomic Dysreflexia
Exaggerated autonomic response to stimulation;
Triggers:
wrinkle in sheets, full bladder pressure, etc.
Most common cause of Autonomic Dysreflexia
SCI spinal cord injury
T6 and above
What is seen Guillian-Barre?
CSF?
Muscle weakness, diminished reflexes, demyelination of nerves
Protein in CSF
Gullian-Barre nursing interventions
Medical emergency due to rapid progression to respiratory failure:
Maintain Respiratory & Improve: TCDB, IS, CPT
bulbar weakness impairs ability to swallow & clear secretions - suctioning
Enhance Mobility: DVT, pressure ulcers
Nutrition: prevent ileus, IV fluids
Communication
Decrease fear & Anxiety
Order of Priority Intervention in Burn Patient
1. Obtain VS & hemodynamic status
2. Calculate TBSA affected
3. Calculate Parkland Formula
4. Dress wound w/sterile gauze
Third Degree Burns (Full Thickness)
Can go into shock
Myoglobin urea (muscle breakdown →stuck in kidneys →hematuria)
Common in older adults due to ↓ sensation
