Final Exam: NUR2755/ NUR 2755 (New 2023 / 2024) Multidimensional Care IV |Complete Guide with Questions and Verified Answers| 100% Correct – Rasmussen
Final Exam: NUR2755/ NUR 2755 (New 2023
/ 2024) Multidimensional Care IV |Complete
Guide with Questions and Verified Answers|
100% Correct – Rasmussen
QUESTION
Earliest sign of increased intracranial pressure
Answer:
Decreased level of con- sciousness
QUESTION
Increased intracranial pressure early signs
Answer:
-EARLIEST SIGN: Decreased level of consciousness
-Restlessness
-Changes in speech
-Confusion
-Headache
-Nausea and vomiting ’ projectile
QUESTION
Increased intracranial pressure late signs
Answer:
-Pupillary changes ’ can mean herniation
-Cranial nerve dysfunction
-Ataxia
-Cushing’s triad (very late sign)
QUESTION
Increased intracranial pressure interventions
Answer:
-Low stimulation
-Semi-fowlers ’ 30 degrees
-Head in neutral position
-Do not cluster activities
-Suction only as needed
-Teach patient not to cough or blow their nose
-Dim lighting
-Stool softeners
-Do not bend or bare down
QUESTION
Increased intracranial pressure treatment
Answer:
IV mannitol given through a filter because it crystallizes at room temperature
QUESTION
Cushing’s triad
Answer:
Severe hypertension, widened pulse pressure (difference be- tween the systolic and diastolic
blood pressure), bradycardia, irregular respirations
QUESTION
Pulse pressure
Answer:
Difference between systolic and diastolic pressure
QUESTION
Ischemic stroke
Answer:
Caused by the occlusion of a cerebral artery by either a thrombus or an embolus.
QUESTION
Thrombotic stroke
Answer:
Occur secondary to the development of a blood clot on an atherosclerotic plaque in a cerebral
artery that gradually shuts off the artery and causes ischemia distal to the occlusion
QUESTION
Embolic stroke
Answer:
Caused by an embolus traveling from another part of the body to a cerebral artery. Blood to the
brain distal to the occlusion is immediately shut off causing neurologic deficits or a loss of
consciousness to instantly occur.
QUESTION
Hemorrhagic stroke
Answer:
Occur secondary to a ruptured artery or aneurysm. The prognosis for a client who has
experienced a hemorrhagic stroke is poor due to the amount of ischemia and increased ICP
caused by the expanding collection of blood. Patients will complain of the “worst headache of
my life”.
QUESTION
Alexia
Answer:
Inability to understand written words
QUESTION
Stroke diagnostics
Answer:
A non-contrast computed tomography (CT) scan (WITH- OUT CONTRAST) is the initial
diagnostic test and should be performed within 25 minutes from the time of client arrival to the
emergency department
QUESTION
Homonymous hemianopsia interventions
Answer:
-Instruct them to use a scanning technique (turning head from the direction of the unaffected
side to the affected side) when eating and ambulating
-Rotate their plate so that they can see it
-Talk to them on their good side
QUESTION
Ischemic stroke treatment
Answer:
-Give thrombolytics within 4.5 hours of initial man- ifestations
-Low-dose aspirin is given within 24-48 hours following an ischemic stroke to prevent further
clot formation
QUESTION
Stroke prevention
Answer:
-Smoking cessation
-Heart-healthy diet rich in fruits and vegetables and low in saturated fats
-Regular activity, including planned exercise; example: walking at least 30 minutes most days of
the week
-Reduction in alcohol consumption
-Reduction of salt in diet
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asystole flat line but patient has pulses present
check EKG attachments
management of angina
MONA
all patients get
morphine
oxygen
nitrates
aspirin
CABG complications
hypotension
hypothermia
hypertension
bleeding
cardiac tamponade
change in level of consciousness
CK MB in MI
30-70 units
detectable 4-6 hours duration 3 days
Troponin T (MI)
0.2
detectable 3 hours
duration 14-21 days
Troponin I (MI)
0.03
decidable 3 days
duration 7-10
cholesterol
less than 200
HDL 35-80
LDL less than 130
triglycerides 35-160
P wave
atrial depolarization and contract
PR interval
travel time from atria to ventricle
QRS
ventricle depolarization and contraction
T wave
ventricle repolarization
EKG little box
0.04 seconds
big box
0.20 seconds
atrial fibrillation
irregular R-R intervals
PR interval : NONE
atrial rate: over 350
risk for blood clots
atrial flutter
atrial rate: 250-350
saw tooth pattern
2,3,4 flutter waves
supra ventricular tachycardia
p waves buried may not be seen
ventricular tachycardia
monomorphic: same shape
polymorphic: different shape
rate 100-250
dead rhythm
asystole
VFIB
ventricular tachycardia
PEA
asystole
no electrical activity
check leads
VFIB
not organized
treatment: CPR, SHOCK, code meds
ventricular tachycardia
pulseless
treatment: CPR, defibrillator
Pulseless Electrical Activity
no pulse
first degree av block
pr interval is prolonged
second degree av block type 1
PR progressively longer
second degree av block type ii
usually wide QRS
third degree av block
complete block
VTACH
rapid response call
VTACH and VFIB are shockable
asystole IS NOT
cardio version on VTACH
QRS complex with no p wave
lack of sinus beats
fibrillation or flutter waves
atrial fibrillation manifestations
Sensations of a fast, fluttering or pounding heartbeat (palpitations)
Chest pain. Dizziness. SOB
hemorrhagic stroke
occur secondary to a ruptured artery or aneurysm
thrombotic stroke
occur secondary to the development of a blood clot on an atherosclerotic plaque in a cerebral artery
gradually shuts off artery and causes ischemia
emboli stroke
embolus traveling from another part of the body to cerebral artery
ischemic strokes
can be reversed with fibrinolytic therapy using alteplase
3-4.5 hr of initial manifestation
contraindicated by active bleeding
GBS
A rare acute inflammatory disorder that affects the axons and or myelin of the PNS
Results in ascending muscle weakness or paralysis
demyelination of peripheral nerves
GBS paralysis occurs
outwards- inwards
respiratory arrest can occur in later stages
ensure airway latency
symptoms of GBS
tingling of lower extremity
Initial muscle weakness and pain
Ascending paralysis
Autonomic dysfunction
GBS causes
autoimmune disease
viral infection
vaccination
Glasgow Coma Scale
lowest score 3- practically dead
highest is 15
coma- 8
GCS
eye opening – 1 to 4
verbal – 1 to 5
motor – 1 to 6
myasthenia gravis
a rare progressive autoimmune disease characterized by muscle weakness as a result of impaired acetylcholine receptors
Affects the voluntary muscles of the body, especially those that control the eyes, mouth, throat and limbs
common symptoms of maysthenia graves
involvement of eye muscles
ocular palsies
Ptosis
Diplopia
weak or incomplete eye closure
tensilon testing
Myasthenic crisis is due to undermedication
Within 30 to 60 seconds after injection of Tensilon, most myasthenic patients show marked improvement in muscle tone that lasts 4 to 5 minutes.
myasthenia crisis
undermedication
cholinergic crisis
overmedication
MS
Chronic autoimmune disease affecting the myelin sheath and conduction pathway of the CNS
Characterized by periods of remission and exacerbation
Hallmark Characteristics
Demyelination
Diffuse patchy areas of plaque in white matter of CNS
ALS
an adult onset upper and lower motor neuron disease characterized by progressive weakness, muscle wasting, and spasticity eventually leading to paralysis
progressive neurodegenerative disease
ALS symptoms
Early symptoms—fatigue while talking, tongue atrophy, dysphagia, weakness of the hands and arms, fasciculations, nasal quality of speech, dysarthria.
cushing triad
sign of increased ICP
-Widening/decreased of pulse pressure
-Slowing HR
- increase systolic BP
-Slowing Respiration: irregular breathing
sources;
https://www.gcu.edu/
https://yaveni.com/
https://www.rasmussen.edu/