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Multiple Sclerosis
ALS
Guilliane-Barre Syndrome
Spinal Cord Injury (SCI)
BURNS
100
There is no specific diagnostic that will confirm MS, only clinical manifestations and history
The oncoming nurse is obtaining shift report for her team of clients. The nurse knows that what diagnostic test will confirm the diagnosis of Multiple Sclerosis?
100
Tongue atrophy and dysphagia
The ER triage nurse knows that the early clinical symptoms of ALS include___?
100
History of a viral illness in the previous weeks
When a history is taken from the client upon admission in the emergency department (ED), would the triage nurse identify as key to a diagnosis of Guillain-Barre syndrome?
100
male gender young adult alcohol and drug use
What population and factors increase the risk for spinal cord injury (SCI)
100
Hyperkalemia and Hyponatremia
In the acute phase of a major burn, what laboratory values are expected to demonstrate an imbalance?
200
Motor impairment, visual disturbances, and paresthesias
During the assessment of a client with exacerbation of MS, what clinical manifestations would nurse expect?
200
Retention of cognitive function with total degeneration of motor function, specifically respiratory function.
When providing care for client with ALS the nurse recognizes what as one of the most distressing clinical symptoms by the client?
200
Ascending paralysis Dyspnea
The nurse knows when caring for a client diagnosed with Guilliane-Barre syndrome, the priority clinical findings include____?
200
Hypertension Flaccid paralysis Severe headache Blurred vision Runny nose Bradycardia Diaphoresis
The nurse knows the clinical manifestations of autonomic dysreflexia include
200
Hyponatremia and Hypokalemia
In the emergent phase of a major burn, what laboratory values are you expected to be imbalanced?
300
Medication management Exacerbation management Safety management
What are the priority teaching needs of the client with MS
300
The Living Will Do Not Resuscitate (DNR)
During care of the client with ALS, maintenance of what is the nurses's priority intervention?
300
Bradycardia
The client with Guilliane-Barre syndrome has respiratory failure and is intubated and the nurse must suction the patient. In assessing the risk for vagal nerve stimulation, what does the nurse closely monitor the client for?
300
Hypotension Loss of reflexes below the injury
The ED nurse is assessing for clinical symptoms of spinal shock which include_______.
300
Burns to the face Singed nose hairs, beard, mustache (facial hair) Edema of the nasal septum Burns to the face, neck and chest Prolonged smoke inhalation
What clinical manifestations does the nurse assess for in a client for the risk of complications of a burn that may lead to respiratory distress?
400
Fatigue Nystagmus Gait instability Visual disturbances Recurrent urinary tract infections (UTI) Mood alterations Irritiability
The nurse is assessing a client diagnosed with MS and expects the clinical manifestations to be
400
There is no clinical or laboratory test specific for this disease
The nurse knows that the diagnostic test used to diagnosis Amyotrophic lateral sclerosis (ALS) would be______?
400
Immunoglobulin (IgA)
The client has been diagnosed with Guilliane-Barre syndrome and the nurse can anticipate the health care provider to order what medications for pharmacological treatment?
400
Ensure the client gets a sufficient quantity of fluid each day Assist the client in developing a schedule Teach the client about high fiber foods
What does the nurse do to implement bowel and bladder retraining for the client with an spinal cord injury?
400
Decreased up to 36 hours after burn Tachycardia High Blood pressure to low blood pressure Pulmonary congestion Altered vital signs Heart failure
Due to the fluid shifts in burn clients, what effects on cardiac output does the nurse expect to see? What would be the clinical manifestations?
500
Safety interventions- side rails up x3, assistance in ambulation Immune suppression (corticorsteriods) Self-care activities
The nurse knows the priority interventions for clients with MS include
500
Assistance in decision about life support measures and DNR implementation Directing the client and family about a Living Will
The nurse knows that the priority interventions for clients diagnosed with ALS would include________.
500
Respiratory assessment and interventions Preparation for intubation
The nurse caring for a client diagnosed with Guilliane-Barre syndrome knows that the priority intervention for this client is _____?
500
Methylprednisolone-reduces inflammation Dextran-increases capillary blood flow Atropine-increase heart rate Dopamine-regulates blood pressure Dantrolene-relieves spasticity
What are common medications that a nurse can expect the health care provider to order with clients with spinal cord injury (SCI)?
500
Age greater than 60 years Burn greater than 40% TBSA Presence of an inhalation injury Age less than 5 years Comorbidities
Factors that increase the risk of death for burn clients (Select all that apply)