A
What is the preferred diagnostic test for multiple sclerosis?
MRI - helps identify comorbidities and monitor the course of the disease progression
What is a complication of influenza?
compromised alveolar function in the lungs
Describe tinnitus
Buzzing sound or ringing in ears
1 Complication of untreated syphilis
Cardiovascular complications (aneurysm, HF, valve disease)
Ocular complications (eye pain, blurry vision, blindness)
Neurological complications (Dementia, meningitis, seizures, vision or hearing loss, muscle weakness)
Congenital complications (passed from mother to baby)
Most common type of spinal cord injury (location)
Cervical
What is Autonomic Dysreflexia?
when your body overreacts to something irritating or painful—like a full bladder, tight clothing, or constipation—but your brain can’t properly control the reaction because of the spinal cord injury.
What happens:
A cause from below the injury tries to reach the brain. The signal gets blocked at the injury site. The body responds by raising blood pressure dangerously high. The brain tries to fix it, but the message can’t get past the injury. This leads to a medical emergency.
Common Symptoms:
Sudden severe headache
Very high BP
Diaphoresis/flushed skin above the injury
Cold pale skin below the injury
Bradycardia
Common triggers:
Bladder issues
Bowel Problems
Skin irritations (tight clothing or pressure sores)
Other (ingrown toenail, infection, pregnancy)
A client presents with cool, clammy skin and diminished peripheral pulses. What is the concern?
Impaired perfusion—the body's tissues and organs are not receiving enough blood flow and oxygen.
What are symptoms from spinal stenosis?
Pain (may radiate)
Numbness or tingling
Weakness
Balance issues (walking)
Foot drop
What are 3 common s/s of hospital acquired delirium
Confusion or disorientation
Restless/Anxious
Hearing voices that are not real
Paranoia or delusions
Disorganized thinking
Agitation
Withdrawal
Mood swings or emotional outbursts
Personality changes
Difficulty sleeping
3 ways to reduce s/s of hospital acquired delirium
Open the blinds during the day
Close the blinds at night
Reduce excess noise
Minimize night time disruptions (VS, noise, alarms)
Reorient patient regularly (date, time location) - use white board
Encourage presence of family/visitors, familiar objects/family photos
Get patient OOB as early and often as possible
Ensure pt has glasses and hearing aids
Monitor Is+Os
Monitor medications (avoid high risk medications like sedatives/opioids)
Wound presents with foul odor and purulent drainage. What is the nurse's next steps?
Notify RN/provider
Diabetic client with ulcer, what is the best way to promote healing?
Monitor blood glucose levels regularly (and keep in target range)
give example of a client who is at risk for :
-friction related skin injury
AND
-moisture related skin injury
Friction: client who needs boosting/moved up in bed
Moisture: client who is incontinent
What are risk factors contribute to erectile dysfunction?
Smoking
Hypertension
Depression / Depression medication
Obesity
Diabetes
Excessive Alcohol use
Recreational drugs
Poor Diet
Chronic Kidney Disease
High Cholesterol
Hormones (imbalance or treatments)
Using the rule of 9s, what percentage is each location worth and what is the TBSA affected
Front of torso
Right palm
Right anterior leg
Bilateral arms
Front torso= 18
Right palm = 1
Right anterior leg = 9
Bilateral Arms 18
TBSA = 46
What actions should a nurse take for a client who is having a seizure?
-Ease client to the floor if standing
-Protect the head
-move furniture/objects away from client
-Time the event
-stay with the patient
-protect the airway/turn pt on side
-loosen tight clothing
Skin is intact but non blanchable redness
Describe stage 2 pressure injury
Partial Thickness Skin loss
-Break in the skin
-Appears as a shallow open sore or blister
-Surrounding skin may be red/swollen/painful
Describe stage 3 pressure injury
Full thickness skin loss
-Damage extends through the dermis into subcutaneous fat
-May appear as a deep crater with or without tunneling
-FAT may be visible but muscle/bone/tendons are NOT exposed
Describe stage 4 pressure injury
Full thickness tissue loss
WITH Exposed muscle, tendon or bone
often includes necrotic tissue, eschar or slough