Seeing Stars
What lab results should we monitor in someone with GBS?
Respiratory labs such as ABGs to monitor and make aware of patients respiratory status as GBS can paralyze these muscles causing respiratory arrest
In which part of the nursing process is the mental status examination done?
during the ASSESSMENT phase
What are some common age related changes seen in relation to the ear?
Dry and wrinkled skin on the auricle, dry cerumen present, hair in the ear canal
What is important postop care for a patient who had a bone biopsy?
Immobilization for 8-12 hours to prevent bleeding
If we suspect an ischemic stroke, what do we give? Within how much time is it effective?
Tissue Plasminogen Activator; within 3-4.5 hours
Who do we use the Tensilon test on? What is a positive tensilon test?
To help diagnose MG. Patient's symptoms will dramatically improve after tensilon
What mental health disorder displays symptoms of survivors guilt?
PTSD
What are the signs and symptoms of cataracts? What causes them?
D/t UV exposure over time; Halos around lights, difficulty reading small print, increased sensitivity when driving at night, diplopia, loss of visual acuity
What are signs of compartment syndrome? What would you do?
Unrelieving pain that gets worse, doesn't go away, not affected by pain medication, asks for pain medication before can have. Notify RN or Dr.
What are the initial signs of increased ICP?
restless, irritable, and decreased LOC
What is a TIA? What could it indicate?
A TIA is a TEMPORARY deprivation of oxygen to the brain. "Mini stroke". It is a warning sign that the patient is at risk for a CVA (stroke).
Projection is a defense mechanism that is described as? Give an example.
Projection in a mental or verbal "finger-pointing" at another for one's own problem.
The student accusing the teacher of trying to fail everyone is an example of projection.
What is the difference between glaucoma and macular degeneration?
Glaucoma is loss of peripheral vision; macular degeneration is loss of central vision
What is Fat Embolism Syndrome? What do we do?
From fractured long bone, fat globules are in the blood stream putting pt at risk for fatty embolism. Keep leg immobilized and hydrate
What is occuring during a cholinergic crisis? What is it due to?
Too much medication; SLUDGE: Salivation, Lacrimation, Urination, Defecation, GI distress, and Emesis
What are the pathophysiological changes of multiple sclerosis vs myasthenia gravis?
MS occurs when demyelination of the myelin sheath and destruction of nerve fibers prevent signals getting to the muscle; MG occurs when the acetylcholine receptors are damaged so there is not acetylcholine to bind to cause a muscle contraction.
What is a flat affect?
Affect describes the outward expression of mood. In a patient who speaks in a monotone voice and has a dull expression has what we call a FLAT affect
What initial screening test would you use to determine gross hearing acuity?
Whisper voice test
A patient is having pain unrelieved by opioids after having a biopsy of the leg about 2 hours ago? What should the nurse do?
Notify the RN or Dr as this could be a sign of bleeding into the soft tissues
What are the 3 different types of HAs? What are they caused by?
Tension HA: stress and muscle contraction of head/neck; Migraine HA: cerebral vasoconstriction followed by vasodilation; Cluster HA: pain in and around the eye due to nerve
What are the different types of aphasia that may occur after a stroke?
Expressive aphasia is when the patient knows what they want to say but cannot speak or make sense. They understand what is being said to them.
Receptive aphasia is when the patient cannot understand spoken or written words.
A patient is displaying agitation, tremors, and hallucinations. He has a history of long-term alcohol abuse. What could be occurring?
Alcohol withdrawal and possible delirium tremens (DTs).
What is the symptom triad in Meniere's Disease?
Hearing loss, vertigo, and tinnitus
A pt with a total hip replacement is supposed to use what type of pillow? What will happen if they don't?
ABductor pillow, leg with surgery can be shortened so keep the legs apart!
What are signs and symptoms of autonomic dysreflexia?
SCI above T6; hypertension, urinary retention, constipation, sweating, pale, goosebumps, EMERGENCY