Neuro
A GCS score of this level is the score that indicates intubation
Hint: (At ____ Intubate)
What is 8?
A nurse is caring for a client with increased intracranial pressure (ICP) following a diagnosis of traumatic brain injury. The client is on a ventilator and requires suctioning. This is a reason why you would LIMIT suction passes
What is to reduce elevation in ICP?
When coup-countercoup occurs, these are the two lobes affected in the brain
What is the frontal and occipital lope?
These are the 2 types of CVA
What are hemorrhagic and ischemic?
You are assessing a patient who came in for abdominal pain. Upon further assessment you notice the patient has a rigid board like abdomen. This would be your 1st and second priority intervention in order
What is contact HCP and make NPO
This is a sign of peritonitis
What is low fiber diet?
You are a nurse caring for a patient who had a right sided mastectomy, name 3 actions you are not able to do the patients right arm
This is due to lack of lymph nodes
What is obtain blood pressure, administer immunizations, draw labs, and IVs
When patient has had a stroke, this is a priority testing for assessing risk of aspiration
What is Swallow test?
These are the Interventions for Ischemic CVA
What is
Maintain patient airway
Obtain STAT CT scan
Perform neuro assessment
Thrombolytics with in 4.5 hours?
For the first 48 hours you would notify the health care provider for a decrease In this scale as this is an indication for increase ICP
What is Glasgow coma scale?
Having a patient with a risk for Increased ICP, you do not want to do this with their care to avoid overstimulation all at once
What is (neuro) cluster care?
This is the minimum number on the GCS for hopes of recovery
What is 9?
This type of hematoma is considered the most deadly
Includes initial loss of consciousness, then followed by brief alertness, then loss of consciousness again
You would want to stay with a patient suspected of this injury due to the high risk of rapid death
What is an epidural hematoma?
This medication is a medication that Breaks up a formed clot (clot buster)
What is TPA (alteplase)?
For a patient having diverticulitis they would be experiencing pain in this quadrant
What is left lower quadrant?
A client just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication?
What is fluid and electrolyte balance?
This Procedure is least invasive for the removal of the prostate.
When medication treatment has not worked for a male patient with BPH, this is the first line of treatment that you would anticipate after
Bloody urine is an expected finding immediately after the procedure
Then light red/ pink urine 24 hours after
What is TURP?
A client with dysphagia is at risk for aspiration. This action by the nurse is most important in helping with dysphagia after a stroke?
What is assist with meals and maintain clients in upright position?
These are the interventions for Hemorrhagic CVA
What is Seizure precautions
Strict bed rest
Limit activity that may increase ICP
(Administer stool softeners to avoid straining is an example)?
These are 3 things you want to make sure you do when positioning your patient with increased ICP
What is keep your patient neutral, log roll when moving, and no flexing?
The nurse is assessing a client following a fall from two stories high. The nurse immediately contacts the health care provider (HCP) after finding clear nasal drainage indicative of basilar skull fracture. These characteristics alerts the nurse to know that the clear nasal drainage is cerebrospinal fluid
What is the fluid separates into rings and tests positive for glucose?
The Glasgow coma Scale assesses these following topics related to neuro status with Traumatic brain injuries
What is best eye response, best verbal response and sensory response?
A patient came into the hospital after falling off of a horse, the patient can not move their legs, and is having incontinence. You can make the make the assumption that they have damaged this part of their spine (C,T,L or S/C/)
What is L (lumbar?)
Name 2 nursing interventions for feeding a person after a stroke
What is
NPO until swallow screen is performed
Flex neck while swallowing
Avoid sedation meds before meals
HOB Up (high fowlers)
Puree diet
Add thickening agents to fluids
A patient is receiving education for diverticulitis flare ups. With respect to diets, the patient would begin as NPO and then increase to these diets (In order, once tolerated)
What is NPO, clear liquid, low fiber, then high fiber diet?
Rigid, board like abdomen, fever and rebound tenderness are signs of this deadly problem in side of the body
What is peritonitis?
Name at least 3 risk factors for breast cancer
What is Being female, Age over 50, Family history of breast cancer, Personal history ( ovarian or uterine cancer, Genetic mutation:BRCA (in men or women), early mensuration age, Weight gain/ obesity, oral contraceptives (due to estrogen and progesterone), High fat/ low fiber diet?
You are seeing a patient who has had a head injury, you see clear fluid coming from his ears, you would perform this next
Passive or active range of motion is a nursing intervention for this stroke complication
What is contracture?
In order for blood vessels to not be extra dilated, which increases ICP you want to ensure this gas keeps below 45 and can be checked with ABG
What is carbon dioxide?
A nurse is assessing a client’s level of consciousness for an unresponsive client. The nurse assesses that the client does not open the eyes; makes incomprehensible sounds; and has abnormal flexion of the extremities. This would be the client’s Glasgow Coma Scale score
What is a score of 6?
The nurse is caring for a client with increased intracranial pressure. Which respiratory pattern changes will signal maximum increased intracranial pressure (the brain stem is crushed)?
What is slow, irregular respirations?
A patient in for a motor vehicle accident resulting in a back injury has decreased blood pressure, dependent edema, and dysregulation of temperature. The patient is most likely experiencing which complication of spinal cord injury
What is neurogenic shock?
This type of aphasia is expressive. Meaning the person can understand but can not express or fully express their communication. The person gets easily frustrated while attempting to speak.
The speech is limited to short phrases
What is Broca Aphasia?
(Think B= Babbling big mouth)
This is the biggest cause of ulcers of the stomach and duodenum?
What is H. pylori?
When educating a patient newly diagnosed with GERD, you would educate them about this in regards to lying down after meals
What is avoid eating before lying down?
What is lay down 3 hours after meals?
What is laying down makes the pain worse?
In terms of diet, you would encourage a patient to switch to this type of diet. Also name 3 examples in this diet
What is High fiber diet?
What are Beans, whole grains, broccoli, cabbage, bran, avocados, lentils, oats?
The nurse is caring for a client with a head injury and his next dose of mannitol will be in two hours. The nurse receives lab results for the client revealing BUN 49 mg/dL, creatinine 19 mg/dL, Na 160 mEq/L, and a serum glucose of 19 mmol/L. This would be your priority action
What is contact the HCP with the lab results before administration of the drug?
When a patient has paralysis on half of their body, you would move and guide this side of their body first
What is the unaffected( stronger side)?
When monitoring the eyes for increased ICP, this term is the descriptor that you would want the eyes to be. This is when the eyes stay looking forward when the head is turned
What is dolls eyes?
This type of closed TBI is considered minor
This type is followed by a brief loss of consciousness, headache and retrograde amnesia
(It is not common to see projectile vomiting, or vision changes with this one)
What is a concussion?
This type of Traumatic Brain injury is also called a basilar skull fracture
Cerebrospinal fluid leakage from the Eyes, ears, nose
The Cerebrospinal fluid is also positive for glucose
What is an Open TBI
These are 3 DO NOTS for a stroke patient to promote independence and dignity
What is Do not complete tasks for the client
What is do not speak loud speak loudly, speak normally
What is do not give complex instructions?
This type of aphasia is receptive, meaning that they can not understand Words and speech. They have a misunderstanding to verbal cues. What people say doesn't make sense.
What is Wernicke Aphasia?
(Think Word soup=Wernicke)
A patient with a new colostomy has a beefy red stoma center, however it has grey outer edges. This is the first action you should take
What is notify the HCP?
Name at least 3 foods to avoid (NO TOBACCO SHOULD BE OBVIOUS) you should educate a patient about with GERD
What is Fried food, Fatty foods, Citrus, Chocolate, Peppermint/spearmint, Caffeine, Alcohol (excessive)
You would educate patients to get this vaccine to decrease and lower the risk of getting this virus and developing cervical cancer
What is HPV vaccine?
This is the first priority of a patient with a head or spinal injury
What is Stabilize cervical spine "C-spine"?
You would implement these precautions for a person having a hemorrhagic stroke
What are seizure precautions?
This is the earliest sign for increased ICP
What is mental status change? (Can also show up as restlessness/ agitation or other mental behaviors)