Neuro
Neuro pt.2
Neuro pt 3
Strokes
GI
GI pt. 2
Male and female reproductive
Nursing Priority
Interventions
ICP
100

A GCS score of this level is the score that indicates intubation 

Hint: (At ____ Intubate)

What is 8?

100

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?

100

When coup-countercoup occurs, these are the two lobes affected in the brain

What is the frontal and occipital lope?

100

These are the 2 types of CVA

What are hemorrhagic and ischemic? 

100

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

100
A patient has a new ileostomy. The nurse should encourage this diet for the first 4-6 weeks postoperatively

What is low fiber diet?

100

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

100

When patient has had a stroke, this is a priority testing for assessing risk of aspiration

What is Swallow test?

100

 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?


100

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?

200

 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?

200

This is the minimum number on the GCS for hopes of recovery

What is 9?

200

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?

200

This medication is a medication that Breaks up a formed clot (clot buster)

What is TPA (alteplase)?

200

For a patient having diverticulitis they would be experiencing pain in this quadrant

What is left lower quadrant?

200

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?

200

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?

200

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?

200

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)?

200

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?

300

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?

300

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?

300

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?)

300

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 

300

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?

300

Rigid, board like abdomen, fever and rebound tenderness are signs of this deadly problem in side of the body

What is peritonitis?

300

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?

300

You are seeing a patient who has had a head injury, you see clear fluid coming from his ears, you would perform this next 

What is check the drainage for glucose?
300

Passive or active range of motion is a nursing intervention for this stroke complication

What is contracture?

300

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?

400

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?

400

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?

400

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? 

400

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)

400

This is the biggest cause of ulcers of the stomach and duodenum?

What is H. pylori?

400

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?

400

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?

400

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?

400

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)?

400

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?

500

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?

500

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

500

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?

500

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) 

500

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?

500

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)

500

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?

500

This is the first priority of a patient with a head or spinal injury 

What is Stabilize cervical spine "C-spine"?

500

You would implement these precautions for a person having a hemorrhagic stroke 

What are seizure precautions?

500

This is the earliest sign for increased ICP

What is mental status change? (Can also show up as restlessness/ agitation or other mental behaviors)