SCI
In a C6 spinal injury, what would the nurse anticipate as the client's self-care ability?
Self-propel in w/c, can transfer from chair to bed, feed self with assistive devices, able to write and care for self.
The most important thing to assess in a client with a head/brain injury is?
Level of consciousness!
Brudzinski's sign
Flexing the head involuntarily flexes the knees and hips (looks like doing crunches "Bruh, you're doing crunches! Bruh-dzinski)
What would the nurse implement as part of seizure precautions?
A CD4+ count between 200-499 cells/mm3 is what stage of HIV?
Stage 2
List the interventions the nurse can implement in managing an episode of autonomic dysreflexia:
HOB 45 degrees (1st), loosen restrictive clothing, check the bed for wrinkles, assess bowel and bladder status, GI disturbances, DVT, pressure ulcer, infection, temp extremes, shoes, pain stimulus
A client is noted to be sniffling and blowing their nose following a head injury, what does the nurse suspect?
CSF leak
Kernig's sign
The client experiences pain or limited motion when the knee is flexed 90 degrees
Define absence seizures:
brief sudden lapses in attention; mostly common in children
What opportunistic infections would the nurse anticipate in AIDS patients?
Kaposi sarcoma (Most common)
Candidiasis, Lymphoma, Pneumocystis jiroveci pneumonia, Tuberculosis
What is the priority intervention for a client w/ SCI?
Airway!
What is the drug of choice given to post-op craniotomy patients and why?
Dexamethasone - to reduce swelling
What are some key differences between a viral & bacterial CSF culture?
Bacterial: Cloudy/turbid appearance, glucose decreased, elevated CSF pressure
Define Tonic-Clonic seizures
Unconsciousness, convulsions, muscle rigidity, lasts 2-5 minutes. Fatigue, acute confusion, and lethargy may last up to an hour after the seizure.
What is PrEP?
For individuals who do not have HIV but who are at substantial risk of getting it to prevent HIV infection by taking specific medications every day
List some signs and symptoms of spinal shock:
On diagnostic imaging, how do you differentiate a subdural hematoma from an epidural hematoma?
Subdural: crescent (banana-shaped) pooling of blood
Epidural: convex (lemon-shaped) pooling of blood
What strains of bacteria would you use droplet precautions for patients with meningitis?
N. Meningitidis and H. Influenzae
Define Atonic seizures
A sudden loss of muscle tone, lasting for seconds, followed by postictal confusion.
What is PEP?
The use of antiretroviral drugs after a single high-risk event to stop HIV seroconversion, it must be taken within 72 hours of possible exposure to be effective.
A female client following an SCI asks the nurse "I won't ever be able to have a baby, will I?" The nurse should explain and teach the client:
Yes, you can get pregnant but will be at an increased risk for bladder infections, pressure sores, HTN & autonomic dysreflexia
Is Cushing's triad a late or early sign of increased ICP? What does the triad consist of?
Late sign - widened pulse pressure, bradycardia and irregular respirations
What are some nursing interventions for spinal headache following a lumbar puncture?
Have the patient lie supine x4 hours s/p puncture, analgesia (avoid ASA or NSAIDs), consider caffeine for temporary relief, increase fluids
A patient is prescribed phenytoin PO for the management of their seizures, what should the nurse stress about this medication with patient teaching?
Signs and symptoms of Phenytoin toxicity – incoordination, slurred speech, nystagmus, nausea, confusion, and dizziness and the importance of lab work for monitoring hepatic function & CBC levels
What are some common side effects of HIV medications?
Lipoatrophy, Lipodystrophy, Hepatotoxicity, Neuropathy, Osteoporosis/Osteopenia Rashes, GI upset (N/V/D), Anemia, Hyperlipidemia, High Cholesterol, High Glucose, Nephrotoxicity, Kidney Stones